Senior Clinical Provider Claims Auditor

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

Benefits offered by this job

Medical insurance

Dental coverage

Vision coverage

Life insurance

Disability benefits

Retirement plan with employer match

Paid time off & holidays

Well-being days

Wellness program

Job summary

Florida Blue Group seeks a senior-level clinical auditor to analyze high-risk provider claims post-payment, validating coding and billing accuracy from a clinical standpoint. You will review medical records, ensure adherence to contracts, and coordinate onsite reviews with provider executives.

The role requires active clinical certification and strong knowledge of DRG and CPT/HCPCS coding, with travel as needed and a hybrid work arrangement.

Qualifications

• 5+ years related work experience with claims/audit background.
• Clinical coding and medical terminology knowledge required.

Responsibilities

• Analyze high-risk claims post-payment to ensure correct coding, billing and payment.
• Audit high-risk claims for policy and industry standard adherence.
• Review medical records to validate coding and billing.
• Determine financial impact based on member benefits and contracts.
• Ensure compliance with regulations (Federal/State/BCBS).
• Lead onsite reviews and close meetings with provider executives.

Skills

ICD-9/10 coding

DRG coding

CPT/HCPCS coding

Claims auditing

Provider contracts

Analytical skills

Communication skills

Excel

Education

Bachelor's degree or related

Active clinical certification (RN/LPN/PA)

Master's degree preferred

Tools

Diamond

Jiva

APT

EIP

Siebel

Quest

Job description

Florida Blue Group seeks a senior-level clinical auditor to analyze high-risk provider claims post-payment, validating coding and billing accuracy from a clinical standpoint. You will review medical records, ensure adherence to contracts, and coordinate onsite reviews with provider executives.

The role requires active clinical certification and strong knowledge of DRG and CPT/HCPCS coding, with travel as needed and a hybrid work arrangement.