Lead Provider Audit Analyst

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Job Summary

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Audit Management: Plan, coordinate, and execute audits of provider records, claims, and documentation to ensure adherence to regulatory requirements and internal policies.
• Quality Assurance: Review and assess the quality of provider services and documentation to identify discrepancies, errors, or areas for improvement.
• Compliance Monitoring: Monitor and enforce compliance with contractual agreements, regulatory guidelines, and industry standards related to provider operations.
• Reporting and Analysis: Prepare detailed audit reports, analyze findings, and recommend corrective actions or improvements to enhance operational efficiency and compliance.
• Training and Development: Provide guidance and training to internal teams or providers on audit findings, compliance requirements, and best practices.
• Collaboration: Work closely with cross-functional teams including Provider Relations, Claims Management, Legal, and Compliance departments to resolve issues and implement process improvements.
• Documentation: Maintain accurate and comprehensive documentation of audit processes, findings, and corrective actions taken.
• Other duties as assigned.
• Understanding of NAIC Coordination Of Benefits (COB) rules, healthcare compliance and relevant regulations, including HIPAA, Medicare, and Medicaid guidelines, in COB and Third-Party Liability processes
• Familiarity with state and federal laws governing COB and TPL
• Proven ability to manage large volumes, interpret complex data sets, identify root causes, develop effective solutions and generate actionable insights.
• Proficiency in using data analysis and report tools/software (e.g. Excel, Access, SQL, Tableau) and other database querying languages to extract and manipulate data to report COB and TPL activities
• Demonstrate experience in streamlining workflows, implementing automation solutions, and standardizing processes to drive operational efficiencies.
• Ability to develop and present comprehensive reports that effectively communicate data insights to stakeholders
• Ability to identify trends and develop data-driven strategies to drive continuous improvement across the organization

Qualifications – what you need to perform the job

Certification and Licensure

• Certifications such as Certified Professional Medical Auditor (CPMA) or similar may be advantageous.

Education

• Required (minimum): Bachelor’s degree in a relevant field such as Healthcare Administration, Business Administration, Finance, or a related discipline.
• Preferred: Master’s degree

Experience

• Required (minimum): 5-7 years of related work experience
• Preferred: 5-7 years of experience in auditing, quality assurance, or provider relations within a healthcare or insurance environment is typically required.

Skill Requirements

• Analytical Skills: Ability to analyze complex data, identify patterns, and draw meaningful conclusions.
• Attention to Detail: Thoroughness and accuracy in reviewing documentation and identifying discrepancies.
• Communication: Clear and effective communication skills, both written and verbal, to report findings and interact with stakeholders.
• Problem-Solving: Ability to investigate issues, propose solutions, and implement improvements.
• Regulatory Knowledge: Understanding of healthcare regulations, compliance requirements, and audit principles (if in healthcare).
• Organizational Skills: Ability to manage multiple audits, prioritize tasks, and meet deadlines effectively.
• Teamwork: Collaborative approach in working with various teams and stakeholders.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent.  We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org