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Provider Auditor Ld

Location: OK
JobFamily: Provider Network Management
Req #: PS60554
Date Posted: Dec 1, 2021

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Description:

Description

SHIFT: Day Job

SCHEDULE: Full-time

Leads the professional audit program for a region and manages the work of vendors contracted to perform audits on the company's behalf. This position will lead the DRG Validation and Re-admissions teams.

 

Primary duties may include but are not limited to:

  • Leads day-to-day activities of the audit team creating and managing workflow assignments, establishing priorities, and serving as resource for training to lower-leveled audit associates.
  • Operates as the SME (subject matter expert for a specific line of business as assigned and documents workflow processes.
  • Collaborates across business lines through the facilitation of meetings. Manages vendor relationships with contracted vendors.
  • Periodically audits work of vendors and ensures that terms of contract are being satisfied.
  • Conducts provider meetings to discuss audit findings and appeals for most complex audits. Negotiates settlements.
  • Researches claims payment methodologies and fee schedule pricing of claims.
  • Reviews and responds to state complaints and prepares cases to escalate for additional review.
  • Adjusts and re-prices claims per audit findings.
  • Assists in resolving contractual issues with providers and in reviewing audit process policy and procedures.
  • Prepares and analyzes various reports to demonstrate recoveries and potential issues with providers.
  • Assists manager with reimbursement/audit initiatives as identified.
  • Supports enterprise initiatives and develops educational materials for internal staff and providers.

 

Minimum Requirements:

  • Requires a BA/BS degree and a minimum of 5 years experience in a related field to include provider audit reimbursement and analytics; project management and leadership experience; or any combination of education and experience which would provide an equivalent background.
  • RN license required

 

Preferred Qualifications:

  • Experience related to medical coding including coding certification and a clinical background strongly preferred.
  • DRG Re-admission experience preferred.
  • NASCO & WGS system experience
  • Recent inpatient CDI experience or a CCDS or CCS with CVA focused audit experience preferred.

 

 

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

Qualifications

Minimum Requirements:

  • Requires a BA/BS degree and a minimum of 5 years experience in a related field to include provider audit reimbursement and analytics; project management and leadership experience; or any combination of education and experience which would provide an equivalent background.
  • RN license required

 

Preferred Qualifications:

  • Experience related to medical coding including coding certification and a clinical background strongly preferred.
  • DRG and Re-admission experience preferred.
  • NASCO & WGS system experience preferred.
  • Recent inpatient CDI experience or a CCDS or CCS with CVA focused audit experience preferred.

 

 

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.