Senior Provider Audit Specialist

Capital Blue Cross•Harrisburg, PA

About The Position

At Capital Blue Cross, the Senior Provider Audit Specialist provides leadership for complex, high-impact audits of hospital billing, chargemaster, and reimbursement practices to drive financial integrity and compliance across the organization. As a subject matter expert on chargemaster structures and reimbursement methodologies, the senior specialist develops audit strategies and frameworks, mentors team members, and provides actionable insights that shape audit strategy, policy development, and provider engagement. Capital Blue Cross offers a comprehensive benefits package and fosters a culture where employees are consistently voted one of the "Best Places to Work in PA", emphasizing going the extra mile for their team and community. The company recognizes work as part of life, prioritizing health and wellbeing, encouraging community involvement, and investing in professional and personal growth through training and continuing education to improve the health and well-being of its members and communities.

Requirements

Expertise in CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies.
Advanced experience with Microsoft Office Suite products (Access, Excel, Word, PowerPoint, etc.), SAS, SQL, Power BI, or other software used for both analytic, reporting, and data visualization functions.
Experience translating audit results into actional recommendations for senior leadership, including financial impact analysis, root cause identification, and strategic process or policy improvements.
Advanced knowledge of hospital reimbursement structures, including DRG/APC payment methodologies, revenue codes, CDMs, UB-04 billing, CPT/HCPCS codes, and revenue cycle operations.
Minimum of five (5) years of progressive experience conducting provider billing, reimbursement, or payment integrity audits within a health plan, consulting firm, or healthcare organization, with a demonstrated focus on hospital chargemasters (CDMs), facility billing, and reimbursement methodologies.
Experience with Commercial and Medicare Advantage plans.
Demonstrated experience independently leading complex, high impact audits, including determining audit scope, methodology, and prioritization based on financial risk, regulatory exposure, and organizational impact.
Bachelor’s degree in healthcare administration, Health Information Management, Accounting, or related field.

Nice To Haves

Master’s preferred
Certified Professional Coder (CPC)
Certified Professional Medical Auditor (CPMA)

Responsibilities

Lead end-to-end audits of provider charge masters (CDM), billing practices, and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements.
Design and enhance audit frameworks, models, dashboards, and templates that standardize audit execution and support enterprise provider audit functions.
Evaluate audit findings and exercise professional judgement to determine materiality, recovery potential and recommended resolution strategies.
Lead or support provider discussions related to audit findings, including explaining methodologies, defending determinations, and recommending corrective actions or process improvements.
Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes
Recommend process improvements, charge containment strategies, and policy changes to ensure appropriate billing and reimbursement practices
Participate in projects related to reimbursement policy development, provider contract review, and audit compliance
Drive proactive analytical studies to assess changes in provider billing patterns, charge description masters and other variable reimbursement provisions.
Provide technical guidance, mentoring, and quality oversight to Provider Audit Specialists, including review of audit workpapers, methodologies, and findings.