Specialist IV-Post-Payment Provider Audit Clinical

WebTPA • FL, FL

6d • $77,600 - $126,100 • Hybrid

About The Position

This is a senior-level technical position in the post-payment provider audit function. The Specialist analyzes assigned provider claims for risks of overpayments and underpayments, performs onsite and desk reviews, and supports the business unit’s objective of ensuring incorrectly billed and paid claims are adjusted to help control medical costs. The role requires an active clinical certification and independently reviews claims from clinical, medical coding, and provider billing perspectives to ensure payment integrity. Reviews include medical records and clinical documentation to validate coding, particularly DRG billing appropriateness, and to confirm claims are paid according to provider and member contracts and standard claims-processing guidelines and billing procedures.

The position also involves direct provider interaction to coordinate onsite reviews and lead closing meetings with provider executives, such as CFOs and managed-care VPs, to present audit findings that may result in claim adjustments. The Specialist identifies upstream process gaps that contribute to incorrect payments and documents them for remediation and prevention.

The position offers a hybrid work arrangement combining flexibility with in-office engagement. Team schedules depend on role requirements and business needs, and travel to corporate or regional offices may be required. Frequent travel is required. The annualized salary range is $77,600–$126,100, with a typical annualized hiring range of $77,600–$97,000. Competitive pay and opportunities for incentive or commission compensation are offered.

Requirements

• At least 5 years of related work experience.
• Strong familiarity with ICD-9/10, DRG, and CPT/HCPCS coding; or experience with and knowledge of multiple provider reimbursement and pricing methodologies, such as DRG, SPC, OFS, POC, global pricing, and per diem; or proficient working knowledge of at least three of the following: medical terminology, claim audit procedures, provider contracts, claims-processing procedures and guidelines, provider authorizations, provider billing, medical coding, and concurrent review.
• Related bachelor’s degree or additional related equivalent work experience.
• Active clinical certification, such as RN, LPN, or PA.
• Ability to travel frequently.
• Proficiency or experience working with some of the following tools and applications: Diamond, Jiva, APT, EIP, Siebel, ICN, Quest, Contract Management System, Burgess, PPS Pricer, AHA Coding Clinic, Encoder, and Alineo.
• Working knowledge of COB/OPL, subrogation, workers’ compensation, standard claims adjustment processes, and benefit plans.
• Working knowledge of personal computers and related software, such as Excel and Microsoft Word.
• Flexibility in unplanned work and/or project support.
• Excellent oral and written communication skills.

Nice To Haves

• Strong analytics experience.
• Consulting experience.
• Master’s degree.
• Professional medical coding certification, such as CPC or CCS, within 18 months of hire.

Responsibilities

• Independently analyze high-risk claims on a post-payment basis using clinical, coding, and claims-processing expertise to determine whether claims were coded, billed, and paid correctly.
• Audit high-risk claims for inappropriate application of company policies and industry-standard billing and care practices that may affect payment, including MCG, LCD, authorizations, covered benefits, and appropriateness of service setting.
• Independently request and review pertinent medical records to validate or invalidate potential issues identified in high-risk claims.
• Determine claim-level financial impact based on member benefits, provider contract terms, and payment policies.
• Ensure claims processing complies with applicable administrative regulations, including federal, Florida state, and BCBS Association requirements.
• Analyze provider coding and billing practices and guidelines at the claim level.
• Plan and maintain an individual audit schedule by coordinating and communicating directly with provider personnel for onsite reviews as needed.
• Document identified issues thoroughly to support claim adjustments, including relevant medical records and clinical or coding rationale.
• Lead onsite closing meetings with provider executives to communicate audit findings and seek agreement before claim adjustments.
• Communicate large or impactful audit findings to appropriate internal parties as needed.
• Identify and document upstream process gaps that drive incorrect payments for remediation and prevention.

Benefits

• Medical, dental, vision, life, and global travel health insurance.
• Life insurance and short- and long-term disability programs.
• Leave programs to support personal circumstances.
• Retirement Savings Plan with employer match.
• Paid time off, volunteer time off, 10 holidays, and 2 well-being days.
• Additional voluntary benefits.
• Comprehensive wellness program.
• Competitive pay and opportunities for incentive or commission compensation.
• Regular annual reviews with pay-for-performance considerations for base pay increases.

What This Job Offers

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