Provider Auditor Ld - #19607LI - Mason, Ohio

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.



 

Provider Auditor, Lead

Mason, Ohio

 

Responsible for leading the professional audit program for a region and for managing work of vendors contracted to perform audits on WLP’s behalf.  Essential duties may include but are not limited to: Leads day-to-day activities of the audit team, providing allocation of resources, establishing priorities, and serving as resource to lower-leveled audit associates. 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 to determine if a claim paid correctly. 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 other reimbursement/audit initiatives as identified through cost of care analysis and regional cross-functional teams. Supports enterprise initiatives and develops educational materials for internal staff and providers as needed. Performs other duties as assigned.

Requires BA/BS and 5 years experience in a related field to include provider audit, reimbursement, and analytics or an equivalent combination of education and experience. Additional education and training related to medical coding, including coding certification and a clinical background is preferred. Requires strong oral and written communication skills, analytical skills, project management and leadership skills.