• Job Description

  Req#: 4515
  Position Description
  
  Base pay is influenced by several factors including a candidate's qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market-driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
  
  At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it's why our employees consistently vote us one of the "Best Places to Work in PA."
  
  The Senior Provider Audit Specialist provides leadership for complex, high-impact audits of hospital billing, chargemaster, and reimbursement practices to drive financial integrity and compliance across the organization. As a subject matter expert on chargemaster structures and reimbursement methodologies, the senior specialist develops audit strategies and frameworks, mentors team members, and provides actionable insights that shape audit strategy, policy development, and provider engagement.
  
  Responsibilities and Qualifications
  
  
  • Lead end-to-end audits of provider charge masters (CDM), billing practices, and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements.
  • Design and enhance audit frameworks, models, dashboards, and templates that standardize audit execution and support enterprise provider audit functions.
  • Evaluate audit findings and exercise professional judgement to determine materiality, recovery potential and recommended resolution strategies.
  • Lead or support provider discussions related to audit findings, including explaining methodologies, defending determinations, and recommending corrective actions or process improvements.
  • Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes
  • Recommend process improvements, charge containment strategies, and policy changes to ensure appropriate billing and reimbursement practices
  • Participate in projects related to reimbursement policy development, provider contract review, and audit compliance
  • Drive proactive analytical studies to assess changes in provider billing patterns, charge description masters and other variable reimbursement provisions.
  • Provide technical guidance, mentoring, and quality oversight to Provider Audit Specialists, including review of audit workpapers, methodologies, and findings.
  
  Skills:
  
  • Expertise in CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies.
  • Advanced experience with Microsoft Office Suite products (Access, Excel, Word, PowerPoint, etc.), SAS, SQL, Power BI, or other software used for both analytic, reporting, and data visualization functions.
  • Experience translating audit results into actional recommendations for senior leadership, including financial impact analysis, root cause identification, and strategic process or policy improvements.
  
  Knowledge:
  
  • Advanced knowledge of hospital reimbursement structures, including DRG/APC payment methodologies, revenue codes, CDMs, UB-04 billing, CPT/HCPCS codes, and revenue cycle operations.
  
  Experience:
  
  • Minimum of five (5) years of progressive experience conducting provider billing, reimbursement, or payment integrity audits within a health plan, consulting firm, or healthcare organization, with a demonstrated focus on hospital chargemasters (CDMs), facility billing, and reimbursement methodologies.
  • Experience with Commercial and Medicare Advantage plans.
  • Demonstrated experience independently leading complex, high-impact audits, including determining audit scope, methodology, and prioritization based on financial risk, regulatory exposure, and organizational impact.
  
  Education and Certifications:
  
  • Bachelor's degree in healthcare administration, Health Information Management, Accounting, or related field. Master's preferred
  • Preferred certifications: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA).
  
  
  About Us
  
  We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you'll help us live our mission of improving the health and well-being of our members and the communities in which they live.

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