Job Details

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together, we will achieve our mission to enhance the health and well-being of the people and communities we serve.

We are seeking a Senior Payment Integrity Auditor to lead the most complex and high-risk audit assignments, ensuring claim payment accuracy and compliance with established billing and coding parameters. This role serves as a subject matter expert (SME) for internal audit staff, provides provider education, and mentors associates on proper audit and claims accuracy methods. The Senior Auditor also identifies new audit opportunities, oversees vendor work, and plays a critical role in fraud detection and process improvement.

Responsibilities:

• Address the most problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters.
• Ensure claim payment accuracy through sound audit review methods and practices, including:
  • Claim payment evaluation
  • Medical chart review
  • Claim payment data analysis
  • Assessment of organizational contractual parameters
• Serve as work, technical, and project subject matter expert for internal IBC audit staff.
• Identify new audit areas through screening and analysis of audit samples.
• Identify and refer potential provider fraud or abuse to management.
• Interact with providers to clarify clinical issues, documentation, and billing practices.
• Document and substantiate billing discrepancies and negotiate resolution when appropriate.
• Initiate and verify claim adjustments, maintain comprehensive audit documentation, and prepare statistical data for leadership reporting.
• Serve as vendor claims processing expert, liaison, or point of contact to ensure successful achievement of vendor deliverables.
• Provide provider education and guidance to associates on proper audit and claims accuracy methods.
• Perform duties of Auditors as required and mentor junior team members.

Qualifications - External

• Education: Bachelor's degree or equivalent.
• Certifications (Preferred, Not Required):
  RHIA, RRA, CCS / CCS-P / CCS-H, ART, CPC, CORT, or RN.
• Experience:
  • Minimum 5+ years of relevant experience in healthcare auditing, coding, or compliance.
• Knowledge & Skills:
  • Extensive knowledge of healthcare provider audit methods, provider payment methodologies, clinical aspects of patient care, medical terminology, and medical record/billing documentation.
  • Demonstrated analytical and investigative skills.
  • Working knowledge of project and work management methods and practices related to provider audit.
  • Technical Skills:
    • Working knowledge of MS Office (Excel, Word, Outlook, SharePoint, Access, etc.).
    • SQL or database knowledge a plus.
  • Excellent communication, negotiation, and leadership abilities.

Fully Remote:
This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app