Auditor 2, Zero Balance

About Us: Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success. JOB SUMMARY: Healthcare Auditors develop contract models for analysis and identify potential insurance reimbursement issues through extensive reviews of hospital claim data and related documents. Auditors also contribute to our knowledge base by conducting research on reimbursement risk areas, reviewing data and processes for quality control, and providing feedback for areas of improvement. ESSENTIAL DUTIES AND RESPONSIBILITIES: Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member. Create and update audit plans, including outlining potential risk areas of a hospital-payer contract based on reimbursement structure and how to manually identify within the data. Model and create/update pricing documents based on hospital contracts to calculate expected payments, including percentage of charge, per diems, MSDRG, outlier and/or stoploss, implants, drugs, Medicare, Medicaid, some outpatient, and other reimbursement models. Review insurance payments, research applicable sources (contracts, state and federal legislation, insurance payer policies, medical records, etc.) to determine if payment is correct and make recommendations on appropriate next steps. Identify contractual and clinical risk areas from commercial and government payors (e.g., Medicare, Medicaid) as well as other specialized audits (such as coordination of benefits and workers’ compensation). Develop specifications and procedures to identify and troubleshoot contractual, coding, and administrative areas of underpayment risk using Access, SQL, Excel, and other programs. Conduct review of zero-balance hospital accounts to identify underpaid inpatient and outpatient claims. Present clear documentation of process, findings, and results of audits. Make recommendations to improve internal processes and external client contracts/processes. Work with data analyst team to build and validate pricing models. Work across project teams to research and outline next steps on identified underpayment trends. Other duties as assigned. MINIMUM QUALIFICATIONS & REQUIREMENTS: High School Diploma or equivalent required Minimum of 3 years of experience working with large sets of (healthcare) data Minimum of 2 years of experience in areas of research and analysis Minimum of 2 years of experience with managed care contracts (government and commercial) and hospital reimbursement Minimum of 2 years of experience working with inpatient claims Minimum of 1 year of experience working with Medicare, Medicaid, outpatient facility claims Minimum of 1 year of experience with contract modeling Ability to translate complex contract language and healthcare data into actionable information and insights Ability to work independently to solve problems and recommend technical solutions (ex. provide calculation/formula to price in Alteryx) Intermediate Excel skills, including knowledge of complex formulas and functions (CONCATENATE, IF, pivot tables) Basic knowledge of Access (link tables, select/update query, manipulate data in tables) and SQL preferred Strong verbal and written communication skills Strong organization skills and attention to detail PHYSICAL DEMANDS: Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines. A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. Originally posted on Himalayas