Auditor

• Create and update audit plans, including outlining potential risk areas of a hospital-payer contract based on reimbursement structure and how to manually identify within the data.
• Model and create/update pricing documents based on hospital contracts to calculate expected payments, including percentage of charge, per diems, MSDRG, outlier and/or stoploss, implants, drugs, Medicare, Medicaid, some outpatient, and other reimbursement models.
• Review insurance payments, research applicable sources (contracts, state and federal legislation, insurance payer policies, medical records, etc.) to determine if payment is correct and make recommendations on appropriate next steps.
• Identify contractual and clinical risk areas from commercial and government payors (e.g., Medicare, Medicaid) as well as other specialized audits (such as coordination of benefits and workers’ compensation).
• Develop specifications and procedures to identify and troubleshoot contractual, coding, and administrative areas of underpayment risk using Access, SQL, Excel, and other programs.
• Conduct review of zero-balance hospital accounts to identify underpaid inpatient and outpatient claims.
• Present clear documentation of process, findings, and results of audits.
• Make recommendations to improve internal processes and external client contracts/processes.
• Work with data analyst team to build and validate pricing models.
• Work across project teams to research and outline next steps on identified underpayment trends.
• Other duties as assigned.

Auditor 2, Zero Balance

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