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Anthem, Inc. Audit & Reimbursement Sr in Smithfield, Rhode Island


SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At National Government Services (NGS), an independent subsidiary of Anthem, Inc. and one of the largest Medicare contractors in the country, it’s a powerful combination. It’s the foundation upon which we’re creating greater access to care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care.

This is an exceptional opportunity to do innovative work that means more to you and those we serve.

NGS Audit & Reimbursement Senior Auditor - Appeals

Work Location – Any NGS Office or Work from Home

This position is part of the Medicare Administrative Contract (MAC) with the Centers for Medicare and Medicaid Services (CMS). This position will support the Medicare part A Audit& Reimbursement department. This includes, but not limited to, processing provider submitted Medicare cost reports. The intent of this position is to support the Medicare cost report appeals workload, however it may include the need to support all functions within the Audit & Reimbursement department. These functions include but not limited to: Cost report acceptance, tentative settlements, rate reviews, desk reviews, audits, final settlements, reopenings, appeals and other compliance/reimbursement review.

Primary duties applicable to the Medicare cost report Appeals workload include, but are not limited to:

  • Manage caseload of Medicare cost report Appeals

  • Position papers

  • Jurisdictional Reviews

  • PRRB Hearings

  • Administrative Resolutions

  • PRRB or CMS requests

  • Monitor all communications related to caseload

  • Maintaining accurate records by updating all logs, case files, tracking systems

  • Perform level 1 or level 2 audit review as part of the appeal process (may also include reopening process) on all areas of the Medicare cost report such as Medicare DSH, Bad Debts, IME/DGME, NAH, Organ Acquisition and all cost based principles

  • Document findings, prepare detailed work papers and present audit adjustment reports in accordance with 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

  • Actively participate in development of Audit & Reimbursement standard operating procedures

  • Activity participate in workgroup initiatives to enhance quality, efficiency and training

  • Participate in all team meetings, staff meetings, and training sessions.

  • Participate on special projects as needed



The requirements listed below are representative of the knowledge, skill and/or ability required:

  • Requires a BA/BS degree, preferably in accounting; 8+ years of audit/reimbursement or related Medicare experience; thorough knowledge of CMS program regulations and cost report format;

  • Knowledge of CMS computer systems

  • Knowledge of the Medicare cost report

  • Knowledge of Medicare Part A Laws, regulations, program manuals and audit policies

  • Must obtain Continuing Education Training requirements. MBA, CPA, CIA or CFE preferred. Demonstrated leadership experience preferred.

  • Must possess effective verbal and written communication skills

  • Experience in Microsoft Office Word, Excel and Outlook

  • Effective organization and time management skills

  • Effective problem solving skills

  • Excellent interpersonal skills with the ability to establish working relationships with individuals at varying levels within the organization

  • Ability to travel may be required

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran.