Providence Auditor Pre-Payment External in Beaverton, Oregon
Providence St. Joseph Health is calling a Auditor Pre-Payment External to our location in Beaverton, OR
Are you an AAPC or AHIMA certified coder? Do you like abstracting chart notes to solve coding challenges and educate providers? Do you want to be part of a team reducing fraud and abuse in healthcare? Then Providence Health Plan would like to hear from you! We are seeking an External Pre-Payment Audit Investigator who will support the compliance related activities of the Special Investigations Unit (SIU) at the Health Plan. This role develops, implements and performs compliance related claim pre-payment auditing and monitoring activities at the Health Plan. This includes the identification, investigation and correction of fraudulent and/or abusive billing and coding practices; coordination of pre-payment chart abstraction prior to benefit application and recovery of overpayments related to fraudulent and/or abusive billing and coding practices; and providing customer service support and education related to coding, medical record documentation requirements, healthcare compliance and fraud, waste and abuse to Health Plan staff, vendors and contracted providers/facilities.
In this position you will have the following responsibilities:
Collaborates with provider contract administration staff, systems administration staff, operations staff, quality medical management staff and provider relations and network development staff on fraud, waste and abuse issues and will actively seek changes required in Health Plan operations and claims adjudication system set up to prevent overpayments for fraudulent and/or abusive billing and coding practices on a pre-adjudication basis.
Works closely with Health Plan legal counsel on pre-payment audit, payment avoidance, and some overpayment recoveries and provider contract terminations related to fraud, waste and abuse audits.
Conduct fraud, waste and abuse pre-payment claim audits in accordance with compliance and External Audit directives and prepare detailed audit reports for management, legal counsel and providers, as requested.
Identify, investigate and resolve billing and coding related inquiries and complaints from beneficiaries, members, regulatory agencies and internal and external customers through pre-payment denials, and education to providers.
Perform data analysis of provider and member payment integrity issues and facilitate business process improvement to ensure health plan compliance.
Act as a resource on compliance issues or questions related to auditing and monitoring activities.
Perform pre-payment audit activities, including on-site record reviews, at provider offices as required.
Participate in and coordinate Provider Appeals process specific to SIU denials and/or overpayment demands.
Required qualifications for this position include:
Bachelor's Degree or an equivalent combination of education and experience.
3 years coding experience with a healthcare provider, facility or health insurance company.
Experience in use of data mining software/tools.
Current coding certification from the American Academy of Professional Coders (AAPC) and/or American Health and Information Management Association (AHIMA) (e.g., CPC, CPC-P, CPC-H, CCS, CCS-P).
Preferred qualifications for this position include:
2 years Fraud and Abuse audit experience in a health insurance company, healthcare provider, facility or other relevant healthcare environment.
Project management experience, education program development experience and group presentation experience.
Current certification as an Accredited Healthcare Fraud Investigator (i.e.; AHFI, CFI).
Certification as an Internal Auditor (i.e. CPMA, CHCA) or Healthcare Compliance (CHC) certification.
About Providence in Oregon.
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple, "Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Internal Audit
Req ID: 292423