Reimbursement Variance Auditor

TSG Resources, Inc.; Tampa (FL); On-site; USD 28,000 - 39,000; Full time

Job summary

SCP Health is seeking a Reimbursement Variance Auditor to perform retrospective reviews of paid accounts, identify underpayments, and optimize reimbursement and cash flow in line with contracts and regulations. You will liaise across A/R, Administration, Ops, and payers to coordinate appeals and resolutions.

The role requires strong data analytics, familiarity with PCM and payer portals, and reliable documentation across departments. Excellent Excel and MS Office skills are essential for success.

Qualifications

• Bachelor’s degree or equivalent work experience in Managed Care or medical billing
• Knowledge of healthcare reimbursement regulations and state/federal laws
• Experience with data mining, reviews, and appeals processes
• Ability to coordinate with multiple stakeholders and maintain detailed records

Responsibilities

• Review appeals and grievances and resolve issues with payer contracts and policies.
• Analyze reimbursement data to identify underpayments and trends.
• Coordinate with payer/plan representatives to resolve payment problems and ensure contract compliance.
• Maintain thorough, accurate notes in payer portals, PCM, Salesforce, and related systems

Skills

Attention to detail

Independent work

Time management

Communication skills

Problem solving

Teamwork

Excel skills

Education

Bachelor’s degree or equivalent experience

Tools

Microsoft Office

Excel

Job description

At SCP Health, what you do matters. As part of the SCP Health team, you have an opportunity to make a difference. At our core, we work to bring hospitals and healers together in the pursuit of clinical effectiveness. With a portfolio of over 8 million patients, 7500 providers, 30 states, and 400 healthcare facilities, SCP Health is a leader in clinical practice management spanning the entire continuum of care, including emergency medicine, hospital medicine, wellness, telemedicine, intensive care, and ambulatory care.

Why you will love working here:

• Strong track record of providing excellent work/life balance.
• Comprehensive benefits package and competitive compensation.
• Commitment to fostering an inclusive culture of belonging and empowerment through our core values - collaboration, courage, agility, and respect.

POSITION SUMMARY:

The Reimbursement Variance Auditor will be responsible for performing a retrospective review of accounts paid by commercial and/or governmental plans by data mining. Determine process to recover lost revenue related to underpayments, optimize reimbursement and cash flow in accordance with federal and state requirements, third party payer contracts and UCR protections which may include follow up with payers to appeal claims. Function as liaison between A/R, Administration, Ops, Systems, Underpayments team and payers / plans, coordinating appeal efforts or resolutions across multiple departments within the Revenue Cycle.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Provide expertise or general support in reviewing, researching, investigating, negotiating, and resolving all types of appeals and grievances.
• Review reimbursement data through both athena IDX Payor Contract Module (PCM) and ad hoc reporting for accuracy of payments, adjustments, and contract procedures.
• Analyze and identify trends for appeals and grievances; provide feedback to manager regarding false positive and true underpayment issues.
• Coordinate with payer / plan or other representatives to resolve inaccurate payment problems or lack of compliance with contract terms; maintain consistent follow-up while keeping thorough, accurate, and concise notes documenting communication with payers / plans.
• Provide feedback to Revenue Cycle related to improvement opportunities and appeal campaigns.
• Utilize payer portal websites, client patient account systems, and internal technology to continually validate activity, payment accuracy, and account status.
• Assist with maintaining current information for all contracts in athena IDX Payor Contract Module (PCM), Salesforce database and Crossmap.
• Maintain thorough knowledge of reimbursement regulations related to assigned territories and/or plan types.
• Ensure that company policies and procedures are current and accurately reflect processes in order to comply with regulatory requirements.
• Other responsibilities, as assigned.

TEAM SPECIFIC DUTIES:

• Contracted Commercial and Governmental Payers: SalesForce database maintenance; administration of non-traditional contracts; resolution of escalated complaints related to contractual adjustments; validation of projected financial impacts for new, renegotiated, or termed Managed Care contracts.
• Hospitalist Governmental Payers: Hospitalist fee schedule audits.
• Emergency Governmental Payers: Chargemaster maintenance and audits; fee schedule audits; RVU updates; maintenance of state Medicare and Medicaid billing requirements.
• Non-Contracted Commercial Auditor: Full examination of all non contracted low payers; test appeal opportunities, create SBAR & P&P on each; responsible for processes on non-traditional appeal projects outside of PCM; create modeler for underpaid appeals in PCM; Fair Health fee schedule maintenance & audits; audit accuracy of PCM builds annually; maintain payer knowledge database; perform annual state deep dive’s and new start facility deep dives.
• Non-Contracted UCR & Special Arrangements: Identify, develop & implement nonstandard agreements as alternative to contracting; maintain SFDC database & notify systems of changes, Audit protections and direct clean ups as needed, maintain hospital employee health plan spreadsheet, assist in high level patient complaints, develop and implement outreach programs to facilities and employer groups as needed, quarterly GRAP payer mapping audits, maintain payer carrier mapping in SFDC for non-par flag.
• Non-Contracted Commercial Arbitration & Underpaid claims auditor: Work with vendor to provide datasets for Arbitration packets & appeal letters, track and monitor all appeal volumes & AOB correspondence. Maintain Arbitration tracker with up-to-date details for all projects. Participate in DOI & arbitration research. Maintain & monitor new state arbitration pilots and other payer specific pilots; Identify & prepare dataset and collaborate with arbitration team on Notice to Arbitrate process. Provide dataset for Emergency Medicine Department & Managed Care Monthly Operations Reviews (MOR)

EDUCATION/EXPERIENCE:

Bachelor’s degree or equivalent work experience years’ previous Managed Care, medical billing, and/or healthcare reimbursement experience Familiarity with a variety of the field's concepts, practices, and procedures

KNOWLEDGE, SKILLS AND ABILITIES:

• Ability to work and independently, displaying a keen eye for attention to detail, and providing accurate status of progress, issues, and risks on all projects.
• Ability to exercise considerable individual judgement and initiative, and to rely on experience and judgment to plan and accomplish goals.
• Ability to work under moderate stress and pressure while maintaining a positive, professional manner both in person and via phone, e-mail, business letter, or fax.
• Ability to produce quality and timely results while handling multiple projects, exhibiting good organizational and time management skills.
• A wide degree of creativity and latitude is expected.
• Must work well with others, exhibiting professional courtesy and excellent customer relation skills.
• Ability to communicate clearly and effectively, both verbally and in writing with all levels of professionals, including executives.
• Ability to effectively problem solve, and to collect and analyze complex data.
• Ability to coordinate projects with diverse groups and individuals.
• Ability to prepare and explain effective reports.
• Willingness to adhere to productivity goals and departmental guidelines.
• Advanced understanding of healthcare reimbursement, and of state and federal insurance laws.
• Proficiency in Microsoft Office products, with advanced Excel skills.

CERTIFICATES AND LICENSES:

None required

WORK ENVIRONMENT AND PHYSICAL DEMANDS:

Job requires a high level of mental awareness Continuous oral & written communication and listening skills Continuous computer use Continuous sitting Occasional bending, kneeling, lifting, pulling & pushing up to 20 pounds

Pay Range:

20.00 - 28.00 USD per hour This range represents the anticipated base salary for this role. Actual compensation will be determined based on experience, qualifications, and internal equity considerations.

Visit our website for further information.

• We offer a comprehensive benefits package designed to support your health, financial well-being, and work-life balance, including medical dental, vision insurance, a 401(k) plan with a company match, paid time off and holidays, professional development support, and employee wellness resources.

Our Work Experience is the combination of everything that’s unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it’s our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.