[Hiring] Provider Audit Specialist @Capital Blue Cross

Role Description

The Provider Audit Specialist supports accurate and compliant provider billing by conducting audits of hospital charge data and claims. This role focuses on analyzing chargemasters (CDMs), identifying billing irregularities, and helping ensure adherence to regulatory and contractual standards. The specialist collaborates with internal teams to recommend improvements and support financial recoveries.

Qualifications

• Proficiency in Microsoft Office Suite products (Access, Excel, Word, PowerPoint, etc.), SAS, SQL, PowerBI, or other software used for both analytic, reporting, and data visualization functions.
• Knowledge of CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies.
• Knowledge of hospital CDMs, UB-04 billing, CPT/HCPCS codes, and revenue cycle operations.
• Familiarity with CMS billing guidelines, DRG/APC reimbursement, and hospital pricing regulations.

Requirements

• 2-4 years in provider auditing, revenue integrity, hospital billing, or charge master analysis.
• Experience with Commercial and Medicare Advantage plans.
• Experience with payer-side claim auditing, payment policy, or charge validation.
• Bachelor’s degree in healthcare administration, Health Information Management, Accounting, or related field.
• Preferred certifications: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA).

Benefits

• Flexible environment prioritizing health and wellbeing.
• Supportive team and encouragement to volunteer in the community.
• Investment in training and continuing education for professional and personal growth.