Senior Provider Auditor occupation at Highmark in Pittsburgh

Highmark is at present looking to employ Senior Provider Auditor on Fri, 07 Jun 2013 03:48:49 GMT. The position is responsible for the review and auditing of paid claims made by Highmark to provider facilities for the purpose of verifying the accuracy of payment and charges and determining the existence of overpayments due to potential fraud, waste and abuse. Audits involve the analysis of charges, CPT/HCPCS coding and unit volumes, member eligibility benefits, appropriateness of services and...

Senior Provider Auditor

Location: Pittsburgh Pennsylvania

Description: Highmark is at present looking to employ Senior Provider Auditor right now, this occupation will be placed in Pennsylvania. For detail informations about this occupation opportunity kindly see the descriptions. The position is responsible for the review and auditing of paid claims made by Highmark to provider facilities for the purpose of verifying the accuracy of payment and charges and ! determining the existence of overpayments due to potential fraud, waste and abuse. Audits involve the analysis of charges, CPT/HCPCS coding and unit volumes, member eligibility benefits, appropriateness of services and supplies, compliance with policy guidelines, and other elements as submitted on the claim. The Senior Auditor together with department analysts compiles and performs trend analysis of paid claim data for purposes of identifying excessive or abusive coding and billing practices. The individual also conducts reviews of provider medical records, charge description masters (CDM) and detailed billing statements on focused audit projects, identifies non-compliance with regulatory and NCCI coding standards, evaluates provider contracts for appropriate payments and pursues payment recoveries and claim adjustments to ensure correct claim payments on audits performed. The Senior Auditor will work closely with analysts, auditors and investigators in the Financial Invest! igations and Provider Review (FIPR) department in the identifi! cation of potential fraud cases and compile necessary documentation to support Highmark's position on overpayment determinations.

Major Accountabilities:
1. Provides clinical expertise and audit reviews on facility audit projects, individual audits, case selections, and payment recovery initiatives.

2. Functions as the clinical team leader for FIPR facility audit group.

3. Identifies new audit areas for trending and data analytic research by analysts.

4. Reviews medical documentation and billing records on problematic paid claims.

5. Identifies fraud or abusive billing patterns and refers potential cases to management appropriately.

6. Interviews medical personnel for clarification of clinical issues to support audit process.

7. Documents and substantiates audit findings to providers.

8. Educates providers on appropriate coding and billing on overpayment recovery issues.

9. Identifie! s and makes revisions with manager to standard audit procedures to enhance effectiveness and productivity.

10. Performs other assignments as directed by management.

Highmark is an Affirmative Action/Equal Employment Opportunity (AA/EEO) employer.

REQUIRED QUALIFICATIONS:

• Bachelor's degree in Nursing, Accounting, Finance, Business Administration.
• Registered Nurse, Registered Health Information Administrator / Technician, Certified Coding Specialist, or Certified Professional Coder.
• Minimum of six (6) years auditing experience of healthcare institutions or eight (8) years experience in acute care hospital or health insurance setting.
• In lieu of degree or certification, a minimum of 5 years experience in related field is required.
• Must have in-depth knowledge of provider facility payment methodology and clinical aspects of patient care including diagnosis and procedures, medical terminology, med! ical record documentation and coding and billing proficiency.
• ! Must have understanding of technical and financial aspects of the health insurance industry.
• Able to work independently.
• Strong personal computer skills, along with the ability to use fraud/abuse data mining tools are required.
• Must possess excellent communication skills and be detailed oriented.
• Strong organizational skills needed.

PREFERRED QUALIFICATIONS:

• Experience in hospital HIM, Internal Audit, Reimbursement or Revenue Cycle departments preferred.

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If you were eligible to this occupation, please email us your resume, with salary requirements and a resume to Highmark.

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This occupation starts available on: Fri, 07 Jun 2013 03:48:49 GMT

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