Provider Audit Specialist

Position Description

The Provider Audit Specialist supports accurate and compliant provider billing by conducting audits of hospital charge data and claims. This role focuses on analyzing chargemasters (CDMs), identifying billing irregularities, and helping ensure adherence to regulatory and contractual standards. The specialist collaborates with internal teams to recommend improvements and support financial recoveries.

Responsibilities and Qualifications

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).

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.