Provider Audit Specialist - LPN or RN
HybridColumbia, South Carolina, United States
Columbia, South Carolina, United StatesHybridFull TimeLicense Or CertificationLarge
Full TimeLicense Or CertificationLarge
Job Summary
Conduct institutional audits to assess provider billing and identify aberrant claims impacting reimbursement. Review hospital itemized bills and medical records to verify covered services, research related claims, and analyze high-dollar claims for timely processing. Coordinate onsite evaluations at hospital locations throughout South Carolina, document findings, and notify claim operations departments of discrepancies. Recover overpayments using internal tracking systems and respond to provider inquiries regarding audit results.
Required Qualifications
- Associate's in a job related field
- RN licensure
- LPN licensure
- one year of clinical nursing experience
- 3 years of clinical nursing and/or medical audit/investigations experience
- 2 years of medical/surgical bedside experience
- Knowledge of anatomy and physiology
- Knowledge of disease processes
- Knowledge of medical terminology
- Knowledge of patient care practices
- Ability to interpret medical records
- Ability to interpret itemized bills
- Familiarity with hospital billing knowledge
- Knowledge of revenue
- Knowledge of CPT
- Knowledge of HCPCS
- Knowledge of medical coding
- Ability to communicate verbally
- Ability to communicate in writing
- Analytical or critical thinking capabilities
- Problem-solving capabilities
- Attention to detail
- Ability to make sound decisions
- Ability to successfully complete multiple tasks simultaneously
- Ability to work with minimal supervision
- Ability to make appropriate decisions on claims reviewed/audited
- Good time management skills
- Organizational skills
- Ability to handle confidential or sensitive information with discretion
- Detail oriented
- Microsoft Office
- Active, unrestricted RN licensure from the United States and in the state of hire
- Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
- Active, unrestricted LPN licensure from the United States and in the state of hire
- Active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC)
Desired Qualifications
- Knowledge of hospital and physician audit principles
- Knowledge of hospital and physician audit procedures
- Knowledge of reimbursement
- Knowledge of group and/or hospital contracts
- Ability to acquire knowledge of group and/or hospital contracts
- Good team building skills
- Leadership skills
- Knowledge of patient care practices
- Knowledge of anatomy
- Knowledge of disease processes
- Working knowledge of Microsoft Office
- Working knowledge of Word
- Working knowledge of Excel
- Working knowledge of Access
- Working knowledge of Adobe
- Ability to acquire knowledge of Adobe
- Previous experience using the BCBSSC system
- Ability to learn the BCBSSC system
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