Provider Auditor

About the position

A Provider Auditor’s responsibility will include overseeing compliance audit processes and ensuring adherence to regulatory requirements across the organization. A Provider Auditor will support business objectives by managing audit plans and conducting thorough evaluations of internal controls. Key tasks involve developing audit strategies, facilitating approvals, implementing audit procedures, and ensuring compliance with industry standards and regulations, all while managing audit-related budgets and achieving set objectives.

Responsibilities

• Selects providers to be reviewed based on historical results of other reviews with providers, network management input and dollar volume of provider.
• Schedules review with provider, analyzes data to select claims to be reviewed, conducts review using medical charts, medical notes, itemized bills and provider contracts.
• Conducts exit interview with provider management team by presenting preliminary review results.
• Verifies dollar amount on claim is correct in claims system and writes report of the findings of the review and requests payments for any overpayments.
• Identifies aberrant patterns of billing and detects potential abuse.
• Participates in developing and/or reviewing department policies and procedures.
• Works on task forces and committees.

Requirements

• Requires a BA/BS degree and a minimum of 2 years’ relevant work experience; or any combination of education and experience, which would provide an equivalent background.

Nice-to-haves

• Experience working in Facets, Macess, and ACMP strongly preferred.
• Previous experience in auditing, particularly in the healthcare sector is preferred.
• Familiarity with healthcare regulations, billing practices, and compliance standards is preferred.
• Knowledge or experience working with Texas LTSS programs preferred.
• Experience working with Microsoft Word, Excel, and SharePoint preferred.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical benefits
• Dental benefits
• Vision benefits
• Short and long term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources