Payer Audit Specialist

Job Description

Job Description

Overview

The Payer Audit Specialist receives and processes commercial and government payer audit requests for select Pharmerica locations. The Payer Audit Specialist reviews audit requests, compiles and classifies existing documentation, and identifies medical documentation needed to respond effectively and efficiently to these requests. The Payer Audit Specialist performs quality assurance checks of all medical and billing documentation before submission and notifies the Revenue Cycle Management (RCM) Ancillary Services management team or General Manager of any missing items, issues, or trends. The employee must have the ability to analyze, prioritize, problem solve, and multi-task. Above all, qualified candidates should possess exceptional internal and external customer service skills and actively promote Pharmerica’s company culture.

Responsibilities

• Ensures daily accomplishments by working toward individual and company goals for cash collections, payer audits, credit balances, medical records, correspondence, appeals/disputes, accounts receivable over 90 days, and other departmental goals
• Understands and adheres to all applicable state/federal regulations and company policies
• Receives, documents, processes, and tracks all incoming payer audit requests and updates until final resolution is obtained
• Communicates and coordinates across departments to ensure audits receive the proper review, appeals, and resolution
• Coordinates with other departments to obtain documentation and justification for medical services rendered. Assembles documentation, composes appeal responses, and submits back to payers in the required format.
• Responds timely to all payer audit requests and submits responses within payer deadlines
• Analyzes payer audit trends and communicates concerns and process improvement needs to the RCM Ancillary Services management team
• Works within established departmental goals and performance/productivity metrics

Qualifications

• High School diploma/GED or equivalent required; some college a plus
• A minimum of two to four years of experience in revenue cycle management with a strong working knowledge of Managed Care, Commercial, Government, Medicare, and Medicaid reimbursement; audit experience a plus
• Working knowledge of automated billing systems; experience with CPR+ and Waystar a plus
• Working knowledge and application of metric measurements, basic accounting practices, ICD 9/10, CPT, HCPCS coding, and medical terminology
• Solid Microsoft Office skills with the ability to type 40+ WPM
• Strong verbal and written communication skills with the ability to independently obtain and interpret information and compose written audit responses
• Strong attention to detail and ability to be flexible and adapt to workflow volumes
• Knowledge of federal and state regulations as it pertains to revenue cycle management, a plus
• Flexible schedule with the ability to work evenings, weekends, and holidays as needed