Find & Apply For Clinical Auditor / Utilization Reviewer Jobs in Severn, Maryland

Audit & Reimbursement III and Senior

Audit & Reimbursement IIILocation:

? This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Wellpoint Federal is a proud member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.

The Audit and Reimbursement III will support our Medicare Administrative Contract (MAC) with the federal government (The Centers for Medicare and Medicaid Services (CMS) division of the Department of Health and Human Services). Under guided supervision, the Audit and Reimbursement III will gain experience on complex issues involving the Medicare cost report and Medicare Part A reimbursement. They will participate in contractual Audit and Reimbursement workload, and have opportunities to participate on special projects. This position provides a valuable opportunity to gain further experience in auditing and financial analysis within a growing healthcare industry. This position allows for educational opportunities leading to certifications and promotes a well-balanced lifestyle that includes professional networking opportunities.

How you will make an impact

• Analyzes and interprets data and makes recommendations for change based on judgment and experience
• Able to work independently on assignments and under minimal guidance from the manager
• Prepare detailed work papers and present findings in accordance with Government Auditing Standards (GAS) and CMS requirements
• Gain experience with applicable Federal Laws, regulations, policies and audit procedures
• Respond timely and accurately to customer inquiries
• Ability to multi-task while independently and effectively prioritizing work using time management, initiative, project management and problem-solving skills
• Must be able to perform all duties of lower-level positions as directed by management
• Participates in special projects and review of work done by auditors as assigned
• Assist in mentoring less experienced associates as assigned
• Perform complex cost report desk reviews
• Perform complex cost report audits, serving as an in-charge auditor assisting other auditors assigned to the audit
• Dependent upon experience, may perform supervisory review of work completed by other associates
• Analyze and interpret data per a provider's trial balance, financial statements, financial documents or other related healthcare records
• Perform cost report acceptance, interim rate reviews, final settlements and tentative settlements as assigned
• Performs complex calculations related to payment exception requests and reviews exception request work papers prepared by others
• Perform cost report reopenings
• Under guided supervision, participate in completing more complex appeals related work
• Position papers
• Jurisdictional Reviews
• Maintaining accurate records by updating all logs, case files, tracking systems
• Participate in all team meetings, staff meetings, and training sessionsMinimum Requirements
• Requires a BA/BS degree and a minimum of 3 years of audit/reimbursement or related Medicare experience; or any combination of education and experience, which would provide an equivalent background
• This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.

Preferred Skills, Capabilities, and Experiences

• Degree in Accounting preferred
• Knowledge of CMS program regulations and cost report format preferred
• Knowledge of CMS computer systems and Microsoft Office Word and Excel strongly preferred
• MBA, CPA or CIA preferred
• Must obtain Continuing Education Training requirements (w required)
• A valid driver's license and the ability to travel may be required.

Audit & Reimbursement SeniorLocation:

? This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

• _ _Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Wellpoint Federal is a proud member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.

The Audit and Reimbursement Senior will support our Medicare Administrative Contract (MAC) with the federal government (The Centers for Medicare and Medicaid Services (CMS) division of the Department of Health and Human Services). The Audit and Reimbursement Senior will support contractual workload involving complex Medicare cost reports and Medicare Part A reimbursement. This position provides a valuable opportunity to gain advanced experience in auditing and financial analysis within a growing healthcare industry. This position allows for educational opportunities leading to certifications and promotes a well-balanced lifestyle that includes professional networking opportunities.

How you will make an impact

• Evaluate the work performed by other associates to ensure accurate reimbursement to providers
• Assist Audit and Reimbursement Leads and Managers in training, and development of other associates
• Participates in special projects as assigned
• Able to work independently on assignments and under minimal guidance from the manager
• Prepare detailed work papers and present findings in accordance with Government Auditing Standards (GAS) and CMS requirements
• Analyze and interpret data with recommendations based on judgment and experience
• Must be able to perform all duties of lower-level positions as directed by management
• Participate in development and maintenance of Audit & Reimbursement standard operating procedures
• Participate in workgroup initiatives to enhance quality, efficiency, and training
• Participate in all team meetings, staff meetings, and training sessions
• Assist in mentoring less experienced associates as assigned
• Prepare and perform supervisory review of cost report desk reviews and audits
• Review of complex exception requests and CMS change requests
• Perform supervisory review of workload involving complex areas of Medicare part A reimbursement such as Medicare DSH, Bad Debts, Medical Education, Nursing and Allied Health, Organ Acquisition, Wage Index and all cost based principles
• Prepare and perform supervisory review of cost report acceptance, interim rate reviews, tentative settlements and final settlements as assigned
• Prepare and perform supervisory review of cost report reopenings
• Manage caseload of Medicare cost report Appeals
• Position papersVisit the Employer site for more details