Senior Clinical Auditor, Post-Payment Provider Claims

Florida Blue Group; Florida; Hybrid; USD 78,000 - 126,000; Full time

Benefits offered by this job

Medical, dental, vision insurance

Life and disability coverage

Retirement plan with employer match

Paid time off and holidays

Volunteer time off

Wellness program

Job summary

Florida Blue Group in Florida is seeking a senior-level provider audit specialist to analyze high-risk provider claims for payment integrity. You will review clinical records, validate DRG and billing accuracy, and coordinate onsite reviews with provider executives.

Travel is required, and the role includes documenting findings, supporting claim adjustments, and ensuring compliance with state and federal guidelines. Hybrid work arrangement offered.

Qualifications

• Experience with ICD-9/10, DRG, CPT/HCPCS coding or multiple provider pricing methodologies.
• Bachelor’s degree or equivalent work experience and active clinical certification.
• Ability to travel frequently and travel readiness.
• Strong knowledge of claims processing guidelines and provider billing.

Responsibilities

• Independently analyze high-risk claims post-payment to ensure correct coding and payment.
• Review medical records to validate coding and billing decisions.
• Lead onsite reviews and closing meetings with provider executives.
• Document issues with rationale for claim adjustments.
• Coordinate audit schedules with providers and ensure compliance with regulations.
• Identify upstream process gaps causing incorrect payments.

Skills

ICD-9/10 coding

DRG coding

CPT/HCPCS coding

Medical terminology

Claims audit procedures

Provider contracts

Billing guidelines knowledge

Communication skills

Education

Bachelor's degree or equivalent

Active clinical certification (RN/LPN/PA)

Master's degree (preferred)

Tools

Diamond

Jiva

APT

EIP

Siebel

ICN

Quest

Contract Management System

Burgess

PPS Pricer

AHA Coding Clinic

Encoder

Alineo

Job description

Florida Blue Group in Florida is seeking a senior-level provider audit specialist to analyze high-risk provider claims for payment integrity. You will review clinical records, validate DRG and billing accuracy, and coordinate onsite reviews with provider executives.

Travel is required, and the role includes documenting findings, supporting claim adjustments, and ensuring compliance with state and federal guidelines. Hybrid work arrangement offered.