Medical Reviewer III, Medicaid
Empower AI
Senior Provider Audit Specialist
Capital Blue Cross
full-time
Posted on:
Origin: • 🇺🇸 United States • Pennsylvania
Visit company websiteSalary
💰 $63,350 - $119,390 per year
Job Level
Senior
Tech Stack
SQL
About the role
- Lead end-to-end audits of provider charge masters (CDM) and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements
- Review and analyze provider chargemaster data to identify outliers, inconsistencies, or policy violations
- Design and enhance audit models, dashboards, and templates to support enterprise audit functions
- Present high-level findings to executive leadership and support provider negotiation efforts
- Support provider outreach efforts to address audit findings and recommend process improvements
- Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes)
- Recommend process improvements, charge containment strategies, and policy changes to ensure appropriate billing and reimbursement practices
- Participate in projects related to reimbursement policy development, provider contract review, and audit compliance
- Drive proactive analytical studies to assess changes in provider billing patterns, charge description masters and other variable reimbursement provisions
- Mentor junior auditors and help establish best practices for audit execution
Requirements
- Minimum of 5 years in provider auditing, revenue integrity, hospital billing, or charge master analysis
- Experience with Commercial and Medicare Advantage plans
- Experience with payer-side claim auditing, payment policy, or charge validation
- Expertise in CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies
- Knowledge of hospital CDMs, UB-04 billing, CPT/HCPCS codes, and revenue cycle operations
- Advanced experience with Microsoft Office Suite (Access, Excel, Word, PowerPoint), SAS, SQL, PowerBI, or other analytic/reporting/data visualization software
- Familiarity with CMS billing guidelines, DRG/APC reimbursement, and hospital pricing regulations
- Bachelor’s degree in Healthcare Administration, Health Information Management, Accounting, or related field (Master’s preferred)
- Preferred certifications: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA)
