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 with contract language such as percentage of charge, per diems, MSDRG, outlier and/or stoploss, implants, drugs
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)
Conduct review of zero-balance hospital accounts to identify underpaid inpatient 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
Other duties as assigned

High School Diploma or equivalent required
Minimum of 2 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 with contract modeling
Basic Excel skills, including knowledge of simple formulas (SUM, AVERAGE), basic pivot tables and ability to filter and sort data sets
Strong verbal and written communication skills
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)
Strong organization skills and attention to detail

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Auditor, Zero Balance

Key skills