This is a full-time, benefit eligible position that is remote and located in San Diego. Will be required to come into the office at minimum once a month or as needed. Under general supervision, the Senior Provider Auditor utilizes key data to perform analysis and audits of managed care functions such as credentialing, claims, coding, provider information, timely access, or quality data. Maintains and performs ongoing monitoring of data, validation and identifies root cause analysis, risks and resolve data integrity issues. Prepares materials for committees and conducts face to face or remote provider education including the creation of the corrective action plan, training documents, and narrative to support and respond to regulatory deficiencies. Assembles evidence and documentation to investigate allegations of fraud, waste, and abuse.
Key responsibilities include: - Maintaining and updating Virtual Examiner (VE) coding edits to ensure alignment with industry standards, CPT, HCPCS, CMS, NCCI, and payer-specific coding requirements.
- Working directly with the Information Systems (IS) Tapestry team and the VE vendor to develop, implement, and validate coding editor enhancements and updates.
- Performing testing and validation of new coding rules and system changes prior to production implementation.
- Managing coding editor escalations and resolving complex coding and reimbursement issues.
- Serving as the subject matter expert for coding-related inquiries from Claims, Provider Operations, Configuration, Audit, Compliance, and Delegation Oversight teams.
- Coordinating and validating semi-annual Medicare Fee Schedule (MFS) updates and related testing activities.
- Supporting claims payment accuracy initiatives, audit readiness, and compliance requirements.
Qualifications Required Education/Experience/Specialized Skills: - Minimum of three (3) years' experience in healthcare/medical office environment.
- Proficient with all Microsoft Office application.
- Experience leading and facilitating work teams, with superior facilitation, interpersonal, verbal, and written communication skills.
- Strong organizational and analytical skills; innovative with ability to identify, anticipate and solve problems.
- Able to adapt, prioritize and meet deadlines.
- Ability to present to key stake holders including physicians; ability to educate and train all levels of professional staff.
Required Certification/Registration: - Required CCS-P, CCS, CDIP, CCDS, CHC, CIC, COC, CPC, CPMA, CPB, CRC, CDEO, Associate degree, or 5 years of related healthcare experience managing quality or data.
Preferred Education/Experience/Specialized Skills/Certification: - Bachelor's degree and/or college coursework in a related field.
- Knowledge of Epic Tapestry, Health Planet, and Timely Access Compliance and network filing.
- Knowledge of claims processing regulations.
- Experience with coding and HIPPA.
- Strong knowledge of Excel.
