Senior Post-Payment Clinical Claims Auditor

WEB-TPA, Inc.; Florida; Hybrid; USD 78,000 - 126,000; Full time

Benefits offered by this job

Medical insurance

Retirement plan

Paid time off

Job summary

Florida Blue is seeking a senior-level professional to audit post-payment provider claims for payment integrity. This role involves onsite and desk reviews, validation of ICD-9/10, DRG, and CPT/HCPCS coding, and coordination with providers for audit findings.

Responsibilities include reviewing medical records, ensuring contracts and policies are followed, and presenting outcomes to CFOs and VPs. Hybrid work arrangement with travel to corporate or regional offices may be required.

Qualifications

• 5+ years in claims/audit with clinical/coding expertise.
• Bachelor's degree or higher; active clinical certification required.
• Willingness to travel frequently.
• Strong knowledge of ICD-9/10, DRG, CPT/HCPCS coding.
• Proficiency with Excel, Word, and related tools.

Responsibilities

• Independently perform high-risk post-payment claims analysis.
• Review medical records to validate coding and payment accuracy.
• Coordinate onsite reviews and present findings to provider executives.
• Identify process gaps driving incorrect payments and remediation.
• Lead closing meetings and document audit conclusions.

Skills

Clinical coding

Auditing

Medical terminology

Claims processing

Communication

Education

Bachelor's degree or equivalent

Active clinical certification (RN/LPN/PA)

Master's degree (preferred)

Tools

Diamond

Jiva

APt

EIP

Siebel

Job description

Florida Blue is seeking a senior-level professional to audit post-payment provider claims for payment integrity. This role involves onsite and desk reviews, validation of ICD-9/10, DRG, and CPT/HCPCS coding, and coordination with providers for audit findings.

Responsibilities include reviewing medical records, ensuring contracts and policies are followed, and presenting outcomes to CFOs and VPs. Hybrid work arrangement with travel to corporate or regional offices may be required.