Quality Auditor, Hospital Bill Audits & Itemized Bill Review (Program Integrity)

Elevance Health•Indianapolis, IN

2d•Hybrid

About The Position

The Quality Auditor provides quality oversight of hospital bill audits and itemized bill reviews. This role validates the accuracy, supportability, and defensibility of audit findings (pre- and/or post-payment), ensuring alignment with documentation standards, payer policy, and contractual reimbursement requirements. The Quality Auditor identifies opportunities to improve audit performance, reduce overturns, and strengthen audit workflows through structured quality monitoring, feedback, and trend reporting.

Requirements

Requires a BA/BS degree in a related field and a minimum of 7 years reimbursement experience including performing detailed financial modeling and economic analyses; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

Registered Nurse (RN) license
Certifications (any relevant): CCS, CPC preferred
Clinical experience (e.g., acute care, med-surg, ICU, ED, OR, case management, utilization review) preferred
Experience in one or more of the following: payment integrity, clinical auditing, hospital bill audit support preferred
Strong ability to interpret medical records and connect documentation to billed services and audit determinations preferred
Working knowledge of hospital billing concepts (UB-04, revenue codes, itemized bills) and how clinical documentation supports charges and units preferred
Knowledge of common payment policies and guidelines (CMS-based rules as applicable, MCO policies, and/or commercial payer policies) preferred
Familiarity with hospital coding/reimbursement concepts (DRG/APC, chargemaster, NCCI, OPPS/IPPS principles) preferred
Experience with audit platforms/claims systems (payer or vendor tools) preferred

Responsibilities

Perform retrospective quality audits (QA) of audit cases involving inpatient and outpatient facility claims, including itemized bill line validation and supporting documentation review.
Validate that findings are supported, accurately documented, and consistent with audit rationale.
Ensure audit determinations appropriately apply payer policies, coding/billing guidelines, and reimbursement rules (e.g., UB-04/revenue codes, HCPCS/CPT, modifiers, units, bundling/packaging logic, duplicates, late charges, and non-covered items).
Confirm the audit file contains complete evidence to support recoveries/avoidance and to withstand provider appeals.
Apply established QA methodology to evaluate performance consistently.
Identify and classify errors (clinical, billing/technical, documentation, policy application, calculation/reimbursement, communication) and track severity and financial impact.
Maintain quality dashboards and trending reports (e.g., accuracy rate, overturn predictors, top error drivers, rework rates, timeliness, and recurring provider billing issues).
Participate in calibration sessions with reviewers to ensure consistent interpretation of billing criteria and policy standards.
Provide structured feedback to audit teams, including coaching, pattern identification, and recommendations for corrective action plans (CAPs).
Support business reviews by summarizing quality findings, root causes, and improvement opportunities.
Recommend updates to job aids, templates, and audit checklists to reduce variation and improve defensibility.
Escalate high-risk issues (e.g., suspected fraud indicators, repeated noncompliance with requirements, or systemic quality breakdowns) to leadership.