Provider Audit Specialist

Capital Blue Cross • Harrisburg, PA

4h

About The Position

The Provider Audit Specialist supports accurate and compliant provider billing by conducting audits of hospital charge data and claims. This role focuses on analyzing chargemasters (CDMs), identifying billing irregularities, and helping ensure adherence to regulatory and contractual standards. The specialist collaborates with internal teams to recommend improvements and support financial recoveries.

Requirements

• Proficiency in Microsoft Office Suite products (Access, Excel, Word, PowerPoint, etc.), SAS, SQL, PowerBI, or other software used for both analytic, reporting, and data visualization functions.
• Knowledge of CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies.
• Knowledge of hospital CDMs, UB-04 billing, CPT/HCPCS codes, and revenue cycle operations.
• Familiarity with CMS billing guidelines, DRG/APC reimbursement, and hospital pricing regulations.
• 2-4 years in provider auditing, revenue integrity, hospital billing, or charge master analysis.
• Experience with Commercial and Medicare Advantage plans.
• Experience with payer-side claim auditing, payment policy, or charge validation.
• Bachelor’s degree in healthcare administration, Health Information Management, Accounting, or related field.

Nice To Haves

• Preferred certifications: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA).

Responsibilities

• Conduct end-to-end audits of provider charge masters (CDM) and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements.
• Review and analyze provider chargemaster data to identify outliers, inconsistencies, or policy violations.
• Assist in the development and maintenance of audit models, dashboards, and templates to support enterprise audit functions.
• Prepare audit summaries with findings and recommendations.
• Support provider communications regarding audit findings and recommend process improvements.
• Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes.
• Contribute to reimbursement and contract review projects.

Benefits

• Medical, Dental & Vision coverage
• Retirement Plan
• generous time off including Paid Time Off, Holidays, and Volunteer time off
• Incentive Plan
• Tuition Reimbursement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level