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Reimbursement Audit Specialist Temple Health Plan

Company: Baylor Scott & White Healthcare
Location: Temple
Posted on: February 3, 2020

Job Description:

Requisition Number: 19018386
Position Title:
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 opportunities.
  • 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 efficiency.
  • 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 federal regulations.
  • 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 management software.
  • 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 procedures.
  • Organizes and performs random and for-cause audits of reimbursement policies, benefit adjudication, and provider fraud.
  • 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 required.
  • Researches and maintains knowledge and remain current in compliance, reimbursement methodology, billing and coding regulations.
    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 includes*:
      • Immediate eligibility for health and welfare benefits
      • 401(k) savings plan with dollar-for-dollar match up to 5%
      • 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

          City:
          State:
          Community / Marketing Title: Reimbursement Audit Specialist Temple Health Plan
          Company Profile:
          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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