The Senior Provider Audit Specialist leads complex, high-impact audits of hospital billing and charge practices to drive financial integrity and compliance across the organization. As a subject matter expert on chargemaster structures and reimbursement methodologies, the senior specialist develops audit frameworks, mentors team members, and provides actionable insights that shape audit strategy, policy development, and provider engagement.

• Lead end-to-end audits of provider charge masters (CDM) and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements.
• Review and analyze provider chargemaster data to identify outliers, inconsistencies, or policy violations.
• Design and enhance audit models, dashboards, and templates to support enterprise audit functions.
• Present high-level findings to executive leadership and support provider negotiation efforts.
• Support provider outreach efforts to address audit findings and recommend process improvements
• Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes.
• Recommend process improvements, charge containment strategies, and policy changes to ensure appropriate billing and reimbursement practices.
• Participate in projects related to reimbursement policy development, provider contract review, and audit compliance.
• Drive proactive analytical studies to assess changes in provider billing patterns, charge description masters and other variable reimbursement provisions.
• Mentor junior auditors and help establish best practices for audit execution.

Skills:

• Excellent communication and reporting skills, with experience presenting findings to executive stakeholders.
• Expertise in CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies.

Knowledge:

• Knowledge of hospital CDMs, UB-04 billing, CPT/HCPCS codes, and revenue cycle operations.
• Advanced experience with Microsoft Office Suite products (Access, Excel, Word, PowerPoint, etc.), SAS, SQL, PowerBI, or other software used for both analytic, reporting, and data visualization functions.
• Familiarity with CMS billing guidelines, DRG/APC reimbursement, and hospital pricing regulations.

Experience:

• Minimum of 5 years in provider auditing, revenue integrity, hospital billing, or charge master analysis.
• Experience with Commercial and Medicare Advantage plans.
• Experience with payer-side claim auditing, payment policy, or charge validation.

Education and Certifications:

• Bachelor’s degree in Healthcare Administration, Health Information Management, Accounting, or related field. Master’s preferred
• Preferred certifications: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA).

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.