Durham, North Carolina
Lancaster, Pennsylvania
Los Angeles, California
Posted: 20-Feb-25
Location: Temple, Texas
Internal Number: 25002733
JOB SUMMARY
The Reimbursement Audit Specialist prepares and monitors reimbursement schedules with hospitals, physicians and ancillary providers based upon the companies' relationship, volume and market sensitivity. Performs audits and examines provider contracts to identify underpayment and/or potential overpayment opportunities. Coordinates corrective action plans to ensure compliance and/or improvement of performance.
WORK MODEL
Hybrid (Some days in Temple office/other days working from home)
Remote (If from out of state but meets minimal requirements)
ESSENTIAL FUNCTIONS OF THE ROLE
- Develops reimbursement models for hospitals, physicians and ancillary providers based upon financial and actuarials projections. Performs financial investigation to access actual costs prior to contract renegotiations and examines provider contracts to identify underpayment and/or potential overpayment opportunities. Ensures targeted aggregate medical costs meet budget. Ensures that proper incentives are created and financial targets are met.
- Collaborates with Provider Relations in negotiating positions for contracts, based upon information collected from the community, internal physicians, management and the Network Issues Committee. Reviews, examines, and studies provider contracts to validate negotiated rates are consistent and within the recommended guidelines in accordance with departmental policies and procedures.
- Communicates detailed contract requirements to properly administer agreements to Claims, MIS and CCD and ensures that staff are aware of regulatory and quality requirements. Ensures contracts are administered based upon the understanding reached during the negotiation. Validates implemented rates of executed provider contracts and payment rules on contract management software.
- Develops compliance plans, if necessary, to meet established policy, state and federal regulations. Develops and maintains an appropriate evaluation system for documenting and tracking of audits that allows for continued monitoring to ensure compliance. Organizes and performs random and for-cause audits of reimbursement policies, benefit adjudication and provider fraud.
- Conducts, investigates, and reports on audits as assigned to prevent, discover, investigate reimbursement errors, insurance fraud, and abuse in compliance with internal policies and procedures, and state/Federal regulations. Prepares report of audit findings and reviews with management in a clear, concise, professional and timely manner.
KEY SUCCESS FACTORS
- Must understand claims processing capabilities.
- Knowledgeable of current compliance, reimbursement methodology, billing and coding regulations.
- Proficient in the use of spreadsheets and data warehouses.
- Finance and data-based background preferred.
BENEFITS
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
QUALIFICATIONS
- EDUCATION - Bachelor's
- Bachelor must be in hand.
- If "expected Dec 2025" or "In progress", this will not meet the minimal requirements for this position.
- Bachelor must be in hand.
- EXPERIENCE - 3 Years of Experience
- Preferably in the healthcare insurance field