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Provider Auditor

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Network Management
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18326 Requisition #
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What you will get to do:

The Provider Auditor is responsible for executing an audit strategy that has been approved by the leadership of Provider Network and Operations Management, in alignment with regulatory, compliance and Medica policies. The Auditor will hold responsibility of verifying the system setups performed by Provider Network and Operations Management staff. The scope will include auditing contract direction and implementation, credentialing processes and/or provider demographic data loading.

This position plays an integral role in ensuring provider data integrity as it supports all system implementation for provider contracts, new product designs, and cost saving initiatives. This position maintains the integrity of the provider contract by reviewing the submission requests to ensure that contract intent is clearly documented, validating that all required fields are complete, the systems are updated with the necessary information and that all attachments are included in the submission folder. Fulfilling the duties of this position accurately, effectively and in a timely manner directly affects the implementation of provider reimbursement, demographic data and has a direct impact on the accuracy of claims payment, volume of claims adjustments, level of provider service, and degree of financial/legal liability.

The Auditor is tasked with performing both system data compares as well as control or end to end transaction audits. An aptitude for utilizing data analytic tools to compare source system data with the data manually entered into downstream systems will be required to ensure accurate data entry and movement. Control audits will require knowledge of processes, systems and a keen eye in verifying that updates were completed according to policies and procedures.

The Auditor will be working with and have access to materials covered under Minnesota Peer Review Law. It is imperative that the Auditor assure that peer review protections are followed at all times.

This position functions within a production environment with expectations to meet production and quality standards, as established for their role. The Auditor will be faced with shifting priorities, situations where decision making and prioritization is needed and the ability to adapt to change quickly will be key. This position also involves creating or maintaining written documentation related to policies, processes and resources, and/or business requirements, therefore the ability to document information logically and effectively is crucial.

Qualifications:

  • Bachelor's degree, or equivalent work experience
  • 3 years of experience in a data driven support role
  • Working knowledge of PC software (Word, Excel, Access, SharePoint, etc.)
  • Demonstrated proficiency in ad-hoc reporting using standard reporting tools
  • Demonstrated competency in driving process improvements
  • COPIS, COSMOS, CACTUS and/or Symfact database knowledge preferred
  • Issue Resolution experience

Skills & Abilities:

  • Analytical – Must be detail-orientated with an ability to look at the whole as well as the pieces
  • Ability to shift priorities comfortably based upon direction from management
  • Ability to present information in a clear and concise manner
  • Ability to manage projects individually or through cross-functional work groups
  • Ability to identify and implement process improvements
  • Quality focused – attention to detail is critical
  • Accountable – able to meet deadline and turn-around times
  • Understanding of provider contracts, system configuration and/or credentialing processes
  • Creative Thinker – able to suggest change outside of standard protocols

Equal Opportunity Employer Including Veterans & Disabled Individuals

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