Provider Auditor
HealthNow New York Inc. - Buffalo, NY

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Position Summary: The incumbent in this position is responsible for billing validation and recovery functions, including desk audits and on site reviews of inpatient, outpatient and ancillary service claims for providers across all divisions of HealthNow. Duties also include review, research and interpretation of documentation including provider contracts and billing records to identify recovery potential. Additionally, the incumbent will conduct follow-up analysis related to specific issues to ensure no reoccurrence of problem/issue. The incumbent also ensures that audits identified as routine or recurring are completed within contractual timeframes, identifies trends and patterns in claims payment data that result in new recovery opportunities, and works with Special Investigations, Legal Counsel and outside law enforcement when audit results indicate the need for further action.

Primary Job Duties:
  • Utilizes specialized auditing software to identify, validate and communicate incorrect claims billing and/or payment information to professional, facility and ancillary service providers across all HealthNow divisions and lines of business. Validates results with providers and coordinates resolution through the internal adjustment process
  • Utilizes technical expertise and industry knowledge to identify research, develop and prioritize new audit opportunities. Works directly with external auditing software vendor to identify, define, develop and implement custom audit parameters for professional, facility and ancillary service providers across all HealthNow divisions. Properly documents all completed audit assignments
  • Performs routine provider-specific claims audits as requested by internal stakeholders. Verifies audit results with providers and coordinates resolution through the internal adjustment process
  • Works internally to utilize knowledge and expertise to support the development of processes, desk levels and reference materials for correct processing of claims and to support provider contracting in light of current system functionality
  • Actively participates in internal and external meetings. Performs administrative duties such as status reports, aging reports, financial reporting and forecasting, etc. Performs special duties and assignments within scope of expected skills and experience
Required Skills Primary Skills/Knowledge:
  • A thorough understanding of various elements of the operational aspects of the health insurance process such as eligibility, reimbursement and contracting
  • Excellent organizational skills and attention to detail
  • Self-motivated, detail oriented multi-tasker able to meet deadlines
  • Excellent verbal and written communication skills
  • Ability to work independently with minimal supervision
  • High degree of business maturity and demonstrated confidentiality
  • Exhibits professional demeanor and interpersonal skills
  • High energy level and ability to project enthusiasm
  • Polished, professional image and reputation
  • Proficiency in MS Word, Excel, Lotus Notes, Facets and Internet
Required Experience Preferred Education:
  • Associates s Degree in a health care field required
  • Bachelors Degree preferred
Preferred Experience:
  • 3-5 years progressively responsible business experience, some/all of which should be in a health care environment required
  • Knowledge of provider/facility contract administration, claim payment methodologies and expertise in ICD-9 and CPT coding required.
Required Licenses/Certifications:
  • RN, Registered Health Info Tech. (RHIT), or Certified Coder (CPC, CPC-H, CCS)

HealthNow New York Inc. - 18 months ago - save job - block
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