Reimbursement Audit Specialist Temple Health Plan
Company: Baylor Scott & White Healthcare
Posted on: February 3, 2020
Requisition Number: 19018386
External Description: The Reimbursement Audit Specialist Scott &
White Health Plan (SWHP) prepares and monitors reimbursement
schedule with hospitals, physicians and ancillary providers based
upon the companies' relationship, volume and market sensitivity.
Performs audits and analyze provider contracts to identify
underpayment and/or potential over payment opportunities.
Coordinate corrective action plan from audits to ensure compliance
and/or improvement of performance. Ensures targeted aggregate
medical costs meet the budget. The essential duties of the
Reimbursement Audit Specialist SWHP include the following:
- Understands claims processing capabilities and develops
reimbursement models for hospitals, physicians, and ancillary
providers based upon financial and actuarial projections.
- Performs financial analysis to access actual costs prior to
contract re negotiations and analyzes provider contracts to
identify underpayment and/or potential over payment
- Ensures that proper incentives are created and financial
targets are met and develops and implements standards for audit
policies and procedures to increase reimbursement accuracy and
- Collaborates with Provider Relations on the negotiating
position for contracts based upon information collected from the
community, internal physicians, management, and the Network Issues
Committee and previous experience with the entity.
- Communicates detailed contract requirements to properly
administer agreements to Claims, MIS and CCD and ensures that staff
are aware of regulatory and quality requirements and develops
compliance plans if necessary to meet SWHP policy, state and
- Ensures contracts are administered based upon the understanding
reached during the negotiation and validates implemented rates of
executed provider contracts and payment rules on contract
- Develops and maintains an appropriate evaluation system for
documenting and tracking of audits that allows for continued
monitoring to ensure compliance.
- Reviews, examines, and analyzes provider contracts to validate
negotiated rates are consistent and within the recommended
guidelines in accordance with departmental policies and
- Organizes and performs random and for-cause audits of
reimbursement policies, benefit adjudication, and provider
- Conducts, investigates, and reports on audits as assigned to
prevent, discover, investigate reimbursement errors, insurance
fraud, and abuse in compliance with SWHP policies and procedures,
state and federal regulations.
- Prepares report of audit findings and reviews with Management
in a clear, concise, professional, and timely manner as
- Researches and maintains knowledge and remain current in
compliance, reimbursement methodology, billing and coding
The ideal Reimbursement Audit Specialist candidate will be
proficient in the use of spreadsheets and date warehouses and will
have finance and analytical background.
- Location/Facility --- Temple Health Plan
- Specialty/Department/Practice --- Provider Network
- Shift/Schedule --- Full Time days
- Benefits --- Our competitive benefits package
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to
- Tuition Reimbursement
- PTO accrual beginning Day 1
*Note: Benefits may vary based upon position type and/or level.
- Bachelor---s degree required
- Minimum of 3 years of work related experience required
Community / Marketing Title: Reimbursement Audit Specialist Temple
Location_formattedLocationLong: Temple, Texas US
CountryEEOText_Description: We are an equal opportunity employer
committed to ensuring a diverse workforce. All qualified applicants
will receive consideration for employment without regard to race,
color, religion, sex, national origin, disability status, protected
veteran status, or any other characteristic protected by law. To
view the most recent EEO is the Law Poster, click here.
Keywords: Baylor Scott & White Healthcare, Temple , Reimbursement Audit Specialist Temple Health Plan, Accounting, Auditing , Temple, Texas
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