Auditor (intermediate), Zero Balance / Senior Auditor (Advanced), Zero Balance (FT/REMOTE)

Job description

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 review of hospital claim data and related documentation. Auditors contribute to the organization's knowledge base by researching reimbursement risk areas, reviewing data and processes for quality control, identifying opportunities for improvement, and providing recommendations that support client reimbursement recovery and operational excellence. We are currently looking for 1 intermediate and 1 advance Auditor with knowledge of Zero Balance Accounts to join our team. This is a remote position 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. This is a remote position. Essential Duties and Responsibilities Create and update audit plans, including identifying potential risk areas within hospital-payer contracts and outlining methodologies for identifying those risks within claims data. Review insurance payments and supporting documentation, including provider contracts, medical records, payer policies, and federal or state regulations, to determine payment accuracy and identify reimbursement opportunities. Research, analyze, and summarize underpayment issues, financial impacts, reimbursement trends, and recommended actions. Identify contractual and clinical reimbursement risk areas across commercial and government payors, including Medicare, Medicaid, coordination of benefits, workers' compensation, and other specialized audit areas. Develop specifications and procedures to identify and troubleshoot contractual, coding, and administrative underpayment risks using Excel, Access, SQL, and other analytical tools. Conduct reviews of zero-balance hospital accounts to identify underpaid inpatient and outpatient claims. Model reimbursement methodologies and create or maintain pricing documents used to calculate expected payments, including percent of charge, per diem, MS-DRG, outlier/stop-loss, implants, drugs, Medicare, Medicaid, outpatient reimbursement methodologies, and other payment structures. Work collaboratively with data analysts and project teams to develop, validate, and enhance pricing models and audit methodologies. Leverage technical tools and automation opportunities to improve audit efficiency and consistency. Present findings, processes, methodologies, and recommendations through clear documentation and reporting. Recommend improvements to internal processes, audit methodologies, and client contract administration processes. Research emerging reimbursement trends, regulatory changes, and payer practices and communicate findings to internal stakeholders. Other duties as assigned. Additional Senior-Level Responsibilities In addition to the responsibilities listed above, Senior Auditors may: Independently lead complex audit projects and reimbursement investigations. Identify new audit opportunities and reimbursement risk areas. Serve as a subject matter expert on contract interpretation, reimbursement methodologies, and regulatory requirements. Mentor, train, and support less experienced auditors. Develop and maintain training materials and deliver educational sessions. Provide technical guidance and quality review of audit work. Minimum Qualifications & Requirements Education High School Diploma or equivalent required. Bachelor's degree in a related field or equivalent experience preferred. Auditor (intermediate), Zero Balance Minimum 3 years of experience working with large healthcare data sets. Minimum 2 years of experience in research and analysis. Minimum 2 years of experience with managed care contracts and hospital reimbursement. Minimum 2 years of experience working with inpatient claims. Minimum 1 year of experience working with Medicare, Medicaid, and/or outpatient facility claims. Minimum 1 year of experience with contract modeling. Ability to translate complex contract language and healthcare data into actionable insights. Ability to work independently to solve problems and recommend technical solutions. Intermediate Excel skills, including complex formulas, functions, and pivot tables. Basic knowledge of Access and SQL preferred. Strong organizational, analytical, written, and verbal communication skills. Strong attention to detail. Senior Auditor (Advanced), Zero Balance Minimum 5 years of experience working with large healthcare data sets. Minimum 5 years of experience in research and analysis. Minimum 3 years of experience with managed care contracts and hospital reimbursement. Minimum 3 years of experience working with inpatient and outpatient claims. Minimum 2 years of experience with contract modeling. Demonstrated ability to lead complex audits and reimbursement investigations. Ability to mentor, train, and develop staff. Advanced ability to interpret complex contract language and translate findings into actionable recommendations. Ability to develop technical solutions and process improvements independently. Intermediate to advanced Excel skills, including complex formulas, functions, pivot tables, and lookups. Basic knowledge of Access and SQL preferred. Strong organizational, analytical, written, and verbal communication skills. Strong attention to detail. We Offer: Quality of life with a remote predictable, full-time schedule Competitive compensation commensurate to experience Medical, Dental, Vision coverage and more Long-term disability insurance, and life insurance Ample parental leave 401K with company match Certification and Tuition Reimbursement Holidays, paid time off 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.