Baylor Scott & White Health Audit Reimbursement Specialist Jobs in Temple, Texas

Audit Reimbursement Specialist

Location: Health Plan

Hours: Full Time


Required Experience A minimum of 3 years experience required.

Required Education Bachelor


Prepares and monitors reimbursement schedule with hospitals, physicians and ancillary providers based upon the companies' relationship, volume and market sensitivity. Performs audits and analyze provider contracts to identify underpayment and/or potential overpayment opportunities. Coordinate corrective action plan from audits to ensure compliance and/or improvement of performance.


Understands claims processing capabilities and develops reimbursement models for hospitals, physicians, and ancillary providers based upon financial and actuarials projections

Ensures targeted aggregate medical costs meet budget

Performs financial analysis to access actual costs prior to contract renegotiations and analyzes provider contracts to identify underpayment and/or potential overpayment opportunities

Ensures that proper incentives are created and financial targets are met and develops and implements standards for audit policies and procedures to increase reimbursement accuracy and efficiency

Collaborates with Provider Relations on the negotiating position for contracts based upon information collected from the community, internal physicians, management, and the Network Issues Committee and previous experience with the entity

Communicates detailed contract requirements to properly administer agreements to Claims, MIS and CCD and ensures that staff are aware of regulatory and quality requirements and develops compliance plans if necessary to meet Scott and White Health Plan (SWHP) policy, state and federal regulations

Ensures contracts are administered based upon the understanding reached during the negotiation and validates implemented rates of executed provider contracts and payment rules on contract management software

Develops and maintains an appropriate evaluation system for documenting and tracking of audits that allows for continued monitoring to ensure compliance

Reviews, examines, and analyzes provider contracts to validate negotiated rates are consistent and within the recommended guidelines in accordance with departmental policies and procedures

Organizes and performs random and for-cause audits of reimbursement policies, benefit adjudication, and provider fraud

Conducts, investigates, and reports on audits as assigned to prevent, discover, investigate reimbursement errors, insurance fraud, and abuse in compliance with SWHP policies and procedures, state and federal regulations

Prepares report of audit findings and reviews with Management in a clear, concise, professional, and timely manner as required

Researches and maintains knowledge and remain current in compliance, reimbursement methodology, billing and coding regulations

Performs other position appropriate duties as required in a competent, professional and courteous manner


Proficient in the use of spreadsheets and data warehouses

Finance and analytical background preferred

Job Family: Health Plan