Specialist IV – Post-Payment Provider Audit, Clinical

GuideWell Source

. Analyze assigned provider claims for overpayment and underpayment risk .

Posted 10/16/2026full-timeFlorida • United StatesMid-LevelSenior💰 $77,600 - $126,100 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in auditing provider claims for overpayment and underpayment risk, ensuring compliance with federal and state regulations while utilizing strong coding knowledge in ICD-9/10, DRG, and CPT/HCPCS. Proficient in analyzing medical records and documentation to validate billing practices and financial impacts.

Highest-signal resume keywords

ICD-9/10 CodingDRG ValidationClaims Audit ProceduresActive Clinical CertificationMedical Coding Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims Processing ProceduresProvider ContractsMedical TerminologyConcurrent ReviewClaims Adjustment Processes

Soft Skills

Excellent Oral CommunicationExcellent Written CommunicationFlexibility in Unplanned Work

Tools & Technologies

DiamondJivaAPTEIPSiebelICNQuestContract Management SystemBurgessPPS Pricer

Certifications & Qualifications

Active Clinical CertificationProfessional Medical Coding Certification

Industry Keywords

Claims Payment IntegrityMedical Cost ControlProvider Billing PracticesFederal RegulationsFlorida State Regulations

About the role

Key responsibilities & impact

Analyze assigned provider claims for overpayment and underpayment risk
Perform onsite and desk reviews to support claims payment integrity and medical cost control
Independently audit high-risk claims using clinical, coding and claims-processing expertise
Review medical records and clinical documentation to validate DRG and other coding and billing appropriateness
Audit application of Florida Blue policies and industry-standard billing and care practices
Request and review pertinent medical records
Determine claim-level financial impact based on member benefits, provider contracts and payment policies
Ensure compliance with federal, Florida state and BCBS Association administrative regulations
Analyze provider coding and billing practices and guidelines
Coordinate directly with provider personnel to plan and maintain audit schedules
Document issues and supporting clinical, coding and medical-record rationale for claim adjustments
Lead onsite closing meetings with provider executives and communicate audit findings
Communicate significant audit findings to internal parties
Identify and document upstream process gaps for remediation and prevention

Requirements

What you’ll need

5+ years related work experience
Related Bachelor’s degree or additional related equivalent work experience
Active clinical certification (e.g. RN, LPN, PA)
Ability to travel frequently
Strong familiarity with ICD-9/10, DRG, CPT/HCPCS coding, or knowledge of multiple provider reimbursement and pricing methodologies
Proficient working knowledge of at least three of: medical terminology, claim audit procedures, provider contracts, claims processing procedures and guidelines, provider authorizations, provider billing, medical coding, concurrent review
Proficiency/experience with tools/apps such as Diamond, Jiva, APT, EIP, Siebel, ICN, Quest, Contract Management System, Burgess, PPS Pricer, AHA Coding Clinic, Encoder, Alineo
Working knowledge of COB/OPL, Subrogation, Workers’ Comp, claims adjustment processes and benefit plans
Working knowledge of personal computers and software such as Excel and Microsoft Word
Flexibility in unplanned work and/or project support
Excellent oral and written communication skills
Preferred: strong analytics experience
Preferred: consulting experience
Preferred: Masters Degree
Preferred: professional medical coding certification (CPC, CCS, etc.) within 18 months of hire

Benefits

Comp & perks

Medical, dental, vision, life and global travel health insurance
Income protection benefits: life insurance, short- and long-term disability programs
Leave programs to support personal circumstances
Retirement Savings Plan including employer match
Paid time off
Volunteer time off
10 holidays
2 well-being days
Additional voluntary benefits
Comprehensive wellness program
Opportunities for incentive or commission compensation
Annual reviews with pay for performance considerations for base pay increases
Hybrid work arrangement combining flexibility with in-office engagement