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Reimbursement Audit Specialist - Health Plan

Company: Baylor Scott White Health
Location: Temple
Posted on: November 30, 2018

Job Description:

Job Description

Reimbursement Audit Specialist - Health Plan

Preferred Qualifications

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 overpayment 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 renegotiations and analyzes provider contracts to identify underpayment and/or potential overpayment 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
For more information on the facility, please click our Locations link.

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.

Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation's exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it's accepting a calling!
Bachelor's degree required

Minimum of 3 years of work related experience required


United States
S&W Health Plan - West Campus (11042)
1206 W Campus Dr
Temple, 76502

Health PlanInsurance

Keywords: Baylor Scott White Health, Temple , Reimbursement Audit Specialist - Health Plan, Healthcare , Temple, Texas

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