Provider Audit Specialist - LPN or RN

BlueCross BlueShield of South Carolina•Columbia, SC

8d•Hybrid

About The Position

The Provider Audit Specialist prepares for and performs institutional audits to assess provider billing, identify aberrant or potentially fraudulent billing practices, and determine the effect of billing discrepancies on reimbursement. The role reviews claims, hospital itemized bills, and medical records to establish which services and charges are covered or allowable, and researches related claims in the claim system. It also documents cost savings, supports timely claim processing—particularly for high-dollar claims—and ensures provider overpayments are recovered. The specialist analyzes findings and prepares letters and reports explaining discrepancies to providers, communicates findings to claim operations, maintains audit files and tracking tools, and responds to provider inquiries. The role selects appropriate claims for post-payment audit, follows departmental procedures, and coordinates with providers to schedule onsite audit evaluations. It may involve day and overnight travel to hospital locations throughout South Carolina. The position is based at 2401 Faraway Drive, Columbia, South Carolina, with potential for hybrid work after the training period. The full-time schedule is an eight-hour shift between 7:30 a.m. and 5 p.m.

Requirements

Associate's degree in a job-related field, or RN licensure, or LPN licensure plus one additional year of clinical nursing experience; the additional experience cannot count toward the required work experience.
Three years of clinical nursing and/or medical audit or investigations experience, including two years of medical/surgical bedside experience.
Active, unrestricted U.S. RN or LPN license in the state of hire, or an active compact multistate unrestricted RN or LPN license under the Nurse Licensure Compact.
Knowledge of anatomy and physiology, disease processes, medical terminology, and patient care practices to verify medical record accuracy.
Ability to interpret medical records and itemized bills.
Familiarity with hospital billing, revenue, CPT, HCPCS, and medical coding.
Ability to communicate verbally and in writing with all levels of the organization and external parties.
Analytical and critical-thinking skills, problem-solving ability, and attention to detail.
Ability to make sound decisions and timely, accurate decisions on reviewed or audited claims.
Ability to manage multiple tasks simultaneously and work with minimal supervision in a fast-paced environment.
Good time-management and organizational skills.
Ability to handle confidential or sensitive information with discretion.
Microsoft Office skills.
Must not require current or future sponsorship.

Nice To Haves

Knowledge of hospital and physician audit principles, procedures, and reimbursement.
Knowledge of group and/or hospital contracts, or ability to acquire it.
Team-building and leadership skills.
Knowledge of patient care practices, anatomy, and disease processes to verify medical record accuracy.
Knowledge of hospital and physician audit procedures and requirements.
Working knowledge of Microsoft Office, especially Word, Excel, and Access.
Working knowledge of Adobe, or ability to acquire it.
Previous experience using the BCBSSC system to access necessary information, or ability to learn it.

Responsibilities

Conduct institutional reviews and audits to assess provider billing and identify aberrant billing that affects reimbursement.
Complete reviews and respond to inquiries in a timely manner.
Review hospital itemized bills and medical records to determine whether services and charges are covered or may be billed separately.
Research the claim system for other claims related to those being reviewed or audited.
Prioritize timely review of high-dollar claims so claims can be processed for payment.
Analyze audit findings and prepare letters and reports describing discrepancies between medical records and itemized bills.
Notify claim operations departments of high-dollar review findings so claims can be processed for payment.
Complete and maintain audit files and internal tracking tools for each audit.
Ensure provider overpayments are recovered through claim reviews, processing, and internal refund tracking systems.
Respond to provider inquiries about audit findings.
Request and analyze institutional provider reports to identify claims suitable for post-payment audit.
Follow departmental procedures and guidelines to validate claims selected for audit.
Coordinate with providers to schedule onsite audit evaluations in a timely manner.
Provide feedback on department policies and procedures throughout audit and review processes.
Notify management of inconsistencies or changes in billing practices that may indicate fraud or abuse.
Recommend improvements to department productivity, cost effectiveness, and timeliness.
Participate in department committees, staff meetings, and educational opportunities.
Travel to hospital locations throughout South Carolina for onsite audits as needed.