REMOTE)

CorroHealth•TX-Remote, TX

18h•Remote

About The Position

Healthcare Auditors develop contract models for analysis and identify potential insurance reimbursement issues through extensive review of hospital claim data and related documentation. Auditors contribute to the organization's knowledge base by researching reimbursement risk areas, reviewing data and processes for quality control, identifying opportunities for improvement, and providing recommendations that support client reimbursement recovery and operational excellence. We are currently looking for 1 intermediate and 1 advance Auditor with knowledge of Zero Balance Accounts to join our team. This is a remote position.

Requirements

High School Diploma or equivalent required.
Minimum 3 years of experience working with large healthcare data sets (Intermediate).
Minimum 2 years of experience in research and analysis (Intermediate).
Minimum 2 years of experience with managed care contracts and hospital reimbursement (Intermediate).
Minimum 2 years of experience working with inpatient claims (Intermediate).
Minimum 1 year of experience working with Medicare, Medicaid, and/or outpatient facility claims (Intermediate).
Minimum 1 year of experience with contract modeling (Intermediate).
Ability to translate complex contract language and healthcare data into actionable insights (Intermediate).
Ability to work independently to solve problems and recommend technical solutions (Intermediate).
Intermediate Excel skills, including complex formulas, functions, and pivot tables (Intermediate).
Basic knowledge of Access and SQL preferred (Intermediate).
Strong organizational, analytical, written, and verbal communication skills (Intermediate).
Strong attention to detail (Intermediate).
Minimum 5 years of experience working with large healthcare data sets (Senior).
Minimum 5 years of experience in research and analysis (Senior).
Minimum 3 years of experience with managed care contracts and hospital reimbursement (Senior).
Minimum 3 years of experience working with inpatient and outpatient claims (Senior).
Minimum 2 years of experience with contract modeling (Senior).
Demonstrated ability to lead complex audits and reimbursement investigations (Senior).
Ability to mentor, train, and develop staff (Senior).
Advanced ability to interpret complex contract language and translate findings into actionable recommendations (Senior).
Ability to develop technical solutions and process improvements independently (Senior).
Intermediate to advanced Excel skills, including complex formulas, functions, pivot tables, and lookups (Senior).
Basic knowledge of Access and SQL preferred (Senior).
Strong organizational, analytical, written, and verbal communication skills (Senior).
Strong attention to detail (Senior).

Nice To Haves

Bachelor's degree in a related field or equivalent experience preferred.

Responsibilities

Create and update audit plans, including identifying potential risk areas within hospital-payer contracts and outlining methodologies for identifying those risks within claims data.
Review insurance payments and supporting documentation, including provider contracts, medical records, payer policies, and federal or state regulations, to determine payment accuracy and identify reimbursement opportunities.
Research, analyze, and summarize underpayment issues, financial impacts, reimbursement trends, and recommended actions.
Identify contractual and clinical reimbursement risk areas across commercial and government payors, including Medicare, Medicaid, coordination of benefits, workers' compensation, and other specialized audit areas.
Develop specifications and procedures to identify and troubleshoot contractual, coding, and administrative underpayment risks using Excel, Access, SQL, and other analytical tools.
Conduct reviews of zero-balance hospital accounts to identify underpaid inpatient and outpatient claims.
Model reimbursement methodologies and create or maintain pricing documents used to calculate expected payments, including percent of charge, per diem, MS-DRG, outlier/stop-loss, implants, drugs, Medicare, Medicaid, outpatient reimbursement methodologies, and other payment structures.
Work collaboratively with data analysts and project teams to develop, validate, and enhance pricing models and audit methodologies.
Leverage technical tools and automation opportunities to improve audit efficiency and consistency.
Present findings, processes, methodologies, and recommendations through clear documentation and reporting.
Recommend improvements to internal processes, audit methodologies, and client contract administration processes.
Research emerging reimbursement trends, regulatory changes, and payer practices and communicate findings to internal stakeholders.
Independently lead complex audit projects and reimbursement investigations (Senior Auditor).
Identify new audit opportunities and reimbursement risk areas (Senior Auditor).
Serve as a subject matter expert on contract interpretation, reimbursement methodologies, and regulatory requirements (Senior Auditor).
Mentor, train, and support less experienced auditors (Senior Auditor).
Develop and maintain training materials and deliver educational sessions (Senior Auditor).
Provide technical guidance and quality review of audit work (Senior Auditor).