Senior Post-Payment Provider Claims Auditor (Clinical)

Florida Blue Group; Jacksonville (FL); Hybrid; USD 78,000 - 126,000; Full time

Benefits offered by this job

Health insurance

Retirement plan

Paid time off

Job summary

Florida Blue Group in Jacksonville, FL seeks a senior-level auditor for the post-payment provider audit function. This role analyzes assigned provider claims for risk of over and under payments, performing onsite and desk reviews to support cost control.

Requires clinical certification and expertise in medical coding (DRG), CPT/HCPCS, ICD-9/10, and provider billing guidance. You will review records, validate coding, and ensure payments align with contracts and guidelines.

Qualifications

• 5+ years related post-payment provider audit experience.
• Active clinical certification (e.g. RN, LPN, PA) or CPC/CCS in progress within 18 months of hire.
• Bachelor's degree or related equivalent.
• Willingness to travel frequently.
• Strong knowledge of ICD-9/10, DRG, CPT/HCPCS coding and provider reimbursement methods.
• Experience with provider contracts and claims processing guidelines.

Responsibilities

• Independently analyze high-risk claims post-payment to ensure correct coding and payment.
• Audit high-risk claims for policy and billing accuracy (DRG, LCD, authorizations).
• Review medical records to validate coding and billing decisions.
• Determine financial impact based on member benefits and contracts.
• Coordinate onsite reviews with providers and present findings at closing meetings.
• Document issues with rationale to support claim adjustments.
• Identify upstream gaps driving incorrect payments for remediation.

Skills

Clinical coding expertise

DRG coding

CPT/HCPCS coding

Provider contracts knowledge

Claims auditing

Medical terminology

Excel proficiency

Excellent communication skills

Education

Bachelor's degree or related

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 Jacksonville, FL seeks a senior-level auditor for the post-payment provider audit function. This role analyzes assigned provider claims for risk of over and under payments, performing onsite and desk reviews to support cost control.

Requires clinical certification and expertise in medical coding (DRG), CPT/HCPCS, ICD-9/10, and provider billing guidance. You will review records, validate coding, and ensure payments align with contracts and guidelines.