Provider Audit Specialist

Duties and Responsibilities:

• Conduct end-to-end audits of provider charge masters (CDM) and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements.
• Review and analyze provider chargemaster data to identify outliers, inconsistencies, or policy violations.
• Assist in the development and maintenance of audit models, dashboards, and templates to support enterprise audit functions.
• Prepare audit summaries with findings and recommendations.
• Support provider communications regarding audit findings and recommend process improvements.
• Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes.
• Contribute to reimbursement and contract review projects.

Skills:

• Proficiency in Microsoft Office Suite products (Access, Excel, Word, PowerPoint, etc.), SAS, SQL, PowerBI, or other software used for both analytic, reporting, and data visualization functions.

Knowledge:

• Knowledge of CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies.
• Knowledge of hospital CDMs, UB-04 billing, CPT/HCPCS codes, and revenue cycle operations.
• Familiarity with CMS billing guidelines, DRG/APC reimbursement, and hospital pricing regulations.

Experience:

• 2-4 years in provider auditing, revenue integrity, hospital billing, or charge master analysis.
• Experience with Commercial and Medicare Advantage plans.
• Experience with payer-side claim auditing, payment policy, or charge validation.

Education and Certifications:

• Bachelor’s degree in healthcare administration, Health Information Management, Accounting, or related field.
• Preferred certifications: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA).