Senior Provider Audit Analyst
Senior Provider Audit Analyst
Employer Active
Job Alert
You will be updated with latest job alerts via email
Share
Job Alert
You will be updated with latest job alerts via email
Job Description
Who We Are
Point32Health is a leading health and wellbeing organization delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health we are building on the quality nonprofit heritage of our founding organizations Tufts Health Plan and Harvard Pilgrim Health Care where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
We enjoy the important work we do every day in service to our members partners colleagues and communities.
Job Summary
The Sr Provider Audit Analyst is responsible for review of claims for accuracy of coding benefit payment and contract interpretation in accordance to claims processing guidelines Point32Health Medical and Payment Policies and established audit protocols. He/she compiles and analyzes data to identify inaccurate payments and trends for root cause analysis. This position is responsible for recovery of inaccurate payments including analysis drafting of recommendations securing approvals coordination of adjustments with claims and tracking of outstanding dollars. The candidate for this position should be able to think critically about contract and/or policy related issues that have a significant financial operational and relationship impact to Point32Health as well as to its entire provider community. Coding Certification (CPC CCS or equivalent); Maintenance of credential status.Job Description
Key Responsibilities/Duties what you will be doing (top five):
- Accountable for the overall quality and accuracy of assigned individual audits as well as the accompanying data mining analytics and summary reporting.
- Typically manage $.5M to 1M each in recoveries/year. Utilize comprehensive knowledge of CPT HCPCS ICD10-CM diagnosis and procedure codes to assist in claims data analysis related to policies and recovery identification.
- Coordinates findings and recoveries with multiple departments across the organization including but not limited to: Contracting Claims SIU and Finance.
- Responsible for all aspects of project analysis from: conceptualization development of queries programming execution problem identification and resolution recovery reporting and recommendations.
- Integrates data from multiple internal and external resources to develop and present recommendations for recoveries to management.
- Other duties and projects as assigned.
Qualifications what you need to perform the job
Certification and Licensure
- CPC CCS or Equivalent
Education Certification and Licensure
- Required (minimum): Bachelors degree in a related field
- Preferred: Masters degree
Experience (minimum years required):
- Required (minimum): 5-7 years of related professional healthcare experience including familiarity with medical claims processing.
- Preferred: 8-10 years of related work experience
Skill Requirements
- Excellent analytic critical thinking and organizational skills including knowledge of analytic and statistical concepts techniques and methods.
- Proven ability to function independently and creatively.
- Proven analytic experience and skilled at manipulating analyzing and evaluating large data sets at various levels of detail; knowledge of SAS or other programming language (SQL) and advanced use of MS Access and Excel.
Working Conditions and Additional Requirements (include special requirements e.g. lifting travel):
- Must be able to work under normal office conditions and work from home as required.
- Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
- May be required to work additional hours beyond standard work schedule.
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.
Compensation & Total Rewards Overview
As part of our comprehensive total rewards program colleagues are also eligible for variable pay. Eligibility for any bonus commission benefits or any other form of compensation andbenefits remains in the Companys sole discretion and maybe modified at the Companys sole discretion consistent with the law.
Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:
Medical dental and vision coverage
Retirement plans
Paid time off
Employer-paid life and disability insurance with additional buy-up coverage options
Tuition program
Well-being benefits
Full suite of benefits to support career development individual & family health and financial health
For more details on our total rewards programs visit to Diversity Equity Inclusion Accessibility (DEIA) and Health Equity
Point32Health is committed to making diversity equity inclusion accessibility and health equity part of everything we dofrom product design to the workforce driving that innovation. Our Diversity Equity Inclusion Accessibility (DEIA) and Health Equity teams strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming events and an inclusion infrastructure play a role in how we spread cultural awareness train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals who will receive consideration for employment without regard to race color religion gender gender identity or expression sexual orientation national origin genetics disability age or veteran status.
Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact you may contact
Required Experience:
Senior IC
Employment Type
Full-Time
Key Skills
Similar Jobs
Dr. Job is an online platform that connects employers with skilled job seekers, facilitating the search for job opportunities and top talent. Established in 2015. Dr. Job Pro has emerged as the world premier job portal, attracting thousands of job seekers every day from all over the world.
Follow Dr.Job
Dr Job FZ LLC. 2025 © All Rights Reserved