Auditor jobs at Blue Cross & Blue Shield

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together, we will achieve our mission to enhance the health and well-being of the people and communities we serve. The Auditor, Payment Integrity role conducts pharmacy claim audits for Independence Blue Cross to ensure accurate provider payments, detect fraud, waste, or abuse, and improve audit processes. It requires a Certified Pharmacy Technician with at least four years of experience, including pharmacy and audit work, strong analytical skills, and proficiency in Microsoft Office and pharmacy claims systems. * Conduct audits of claims submitted to Independence Blue Cross (IBX) to ensure accuracy of provider payments and charges. * Analyze provider billing patterns to detect potential fraud, waste, or abuse. * Perform audits through daily reviews, live audits, and desk audits to identify inappropriate billing practices. * Review and verify provider billing records, collaborating with CFID audit analysts, auditors, investigators, internal, and external sectors * Execute standard provider audit assignments using sound audit methodologies to uncover patterns of abuse or fraud. * Screen and audit claim samples-both summary and detailed-to select cases for further review. * Initiate and validate claim adjustments, maintain comprehensive audit documentation, and prepare statistical reports. * Identify and escalate potential provider fraud or abuse to management. * Contribute to the development and implementation of new audit processes and functions. Qualifications * Certified Pharmacy Technician (CPhT) required. * Minimum of four (4) years of relevant experience, including: * At least two (2) years in retail or hospital pharmacy. * At least two (2) years in pharmacy audit. * Extensive understanding of healthcare provider audit practices and medical terminology. * Familiarity with fraud, waste, and abuse detection methodologies. * Strong written and verbal communication skills for reporting and presenting audit findings * Proficiency in Microsoft Office applications, including Excel, Word, Outlook, SharePoint, and Access. * Advanced Excel skills (pivot tables, VLOOKUP, data analysis). * Experience with pharmacy claims systems such as RxTrack and RxClaim is preferred but not required. Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device that is compatible with the free Microsoft Authenticator app.

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together, we will achieve our mission to enhance the health and well-being of the people and communities we serve. We are seeking a Senior Payment Integrity Auditor to lead the most complex and high-risk audit assignments, ensuring claim payment accuracy and compliance with established billing and coding parameters. This role serves as a subject matter expert (SME) for internal audit staff, provides provider education, and mentors associates on proper audit and claims accuracy methods. The Senior Auditor also identifies new audit opportunities, oversees vendor work, and plays a critical role in fraud detection and process improvement. Responsibilities: * Address the most problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters. * Ensure claim payment accuracy through sound audit review methods and practices, including: * Claim payment evaluation * Medical chart review * Claim payment data analysis * Assessment of organizational contractual parameters * Serve as work, technical, and project subject matter expert for internal IBC audit staff. * Identify new audit areas through screening and analysis of audit samples. * Identify and refer potential provider fraud or abuse to management. * Interact with providers to clarify clinical issues, documentation, and billing practices. * Document and substantiate billing discrepancies and negotiate resolution when appropriate. * Initiate and verify claim adjustments, maintain comprehensive audit documentation, and prepare statistical data for leadership reporting. * Serve as vendor claims processing expert, liaison, or point of contact to ensure successful achievement of vendor deliverables. * Provide provider education and guidance to associates on proper audit and claims accuracy methods. * Perform duties of Auditors as required and mentor junior team members. Qualifications - External * Education: Bachelor's degree or equivalent. * Certifications (Preferred, Not Required): RHIA, RRA, CCS / CCS-P / CCS-H, ART, CPC, CORT, or RN. * Experience: * Minimum 5+ years of relevant experience in healthcare auditing, coding, or compliance. * Knowledge & Skills: * Extensive knowledge of healthcare provider audit methods, provider payment methodologies, clinical aspects of patient care, medical terminology, and medical record/billing documentation. * Demonstrated analytical and investigative skills. * Working knowledge of project and work management methods and practices related to provider audit. * Technical Skills: * Working knowledge of MS Office (Excel, Word, Outlook, SharePoint, Access, etc.). * SQL or database knowledge a plus. * Excellent communication, negotiation, and leadership abilities. Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app

Your Role The Internal Audit Services team performs internal audits and advisory services to provide assurance on specific internal control objectives and emerging risk areas. The Internal Audit Principal will report to the Internal Audit Senior Director. In this role, you will be leading and managing financial, operational, and integrated audits and advisory engagements. You will also be assessing the design and effectiveness of internal controls for business processes, financial reporting and measurement activities, and related applications in accordance with laws, regulations, policies, standards, and procedures using established tools and techniques.

Our organization is looking to diversify, grow, innovate, and serve, and we are looking for committed, empowered, learning-oriented people to join our team. If this describes you, we want to speak with you. The Payment Integrity Auditor is responsible for conducting complex and high-risk audit assignments to ensure claim payment accuracy and compliance with established billing and coding parameters. This role applies advanced audit methodologies to identify claim overpayments, validate payment integrity, and support organizational goals through detailed analysis and provider engagement. Responsibilities: * Address problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters. * Identify payment methods and factors used in reimbursing targeted claims and apply appropriate audit/payment accuracy methods. * Evaluate and audit samples in summary and in detail to select audit claims. * Examine medical and billing records to identify provider patterns that determine or influence payment. * Interact with providers to clarify clinical issues, documentation, and billing practices. * Document and substantiate billing discrepancies to providers and negotiate resolution when appropriate. * Initiate and verify claim adjustments, maintain audit documentation, and prepare statistical data. * Serve as vendor claims processing lead, liaison, or point of contact to ensure achievement of vendor work. Qualifications: Education: o Bachelor's degree or equivalent. Certifications (Preferred, Not Required): * Registered Health Information Administrator (RHIA) * Registered Records Administrator (RRA) * Certified Coding Specialist - Physician/Hospital (CCS / CCS-P / CCS-H) * Accredited Record Technician (ART) * Certified Professional Coder (CPC) * Certified OR Technician (CORT) * Registered Nurse (RN) Experience: o Minimum 3 years of relevant experience in healthcare auditing, coding, or compliance. Knowledge & Skills: * Working knowledge of healthcare provider audit methods and provider payment methodologies. * Understanding of clinical aspects of patient care, medical terminology, and medical record/billing documentation. * Demonstrated analytical and investigative skills. * Strong proficiency in MS Excel and audit tools. * Excellent communication and negotiation abilities. Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.