Healthcare Audit Specialist

About the Role:

The Audit Specialist supports the Audit department by auditing, submitting, monitoring, and resolving VA
and Medicaid claims for Home Health, Home Health Aide, and Respite Care services. This role requires
strong knowledge of insurance coverage, state-specific billing regulations, authorization requirements,
and timely filing guidelines, particularly for Managed Care Organizations, including extension and
reprocessing timelines. Key responsibilities include correcting claim errors, managing clearinghouse and
payer rejections, resolving denials, tracking appeals and escalations, and ensuring timely and accurate
reimbursement. This individual serves as a subject-matter expert for assigned payers and state billing
requirements and partners with internal teams to resolve complex billing issues.

This position also requires the ability to interpret EOBs, remittances, and EOPs to determine appropriate
next steps, even without direct access to payer portals. The ideal candidate is a proactive problem-solver
who can develop and communicate solutions, write clear provider summaries, and share knowledge by
teaching and supporting the team. Strong attention to detail, disciplined follow-through, flexibility, and the
ability to manage multiple priorities while meeting daily productivity standards are essential. The
specialist serves as a key point of contact for provider escalations and ensures accurate tracking and
documentation in HubSpot. This position reports to the Audit Manager.

Core Responsibilities:

• Audit assigned claims daily to confirm accuracy of:
• Member/patient info, DOS, units/visits, service type
• Diagnosis codes, provider identifiers, authorizations, attachments
• Validate documentation supports billed services (orders, POC, visit notes)
• Submit clean claims via clearinghouse or payer-specific processes
• Apply VA Community Care, VCA, and authorization model rules correctly
• Understand state-specific Medicaid and MCO billing requirements
• Ensure compliance with EVV, COB, eligibility, and medical necessity rules
• Interpret EOBs, RAs, and EOPs to determine next actions
• Resolve clearinghouse and payer rejections within 72 hours
• Identify root causes and correct claims end-to-end
• Prepare and track reconsiderations, appeals, and escalations
• Monitor timely filing, corrected claim, and resubmission windows
• Perform biweekly follow-ups on unadjudicated and adjudicated claims
• Run and interpret daily/weekly reports for:
• Rejections, denials, underpayments, pending claims, timely filing risks
• Maintain clear, complete audit documentation in HubSpo

Experience and Skills:

• Minimum of 1-3 years of experience in home health billing, audits, denials, and appeals (VA
  and/or Medicaid strongly preferred)
• Strong understanding of authorizations, eligibility, and payer rules
• Experience with clearinghouses, payer portals, and claim corrections
• Excellent organization, documentation, and follow-through
• Proficient in MS Office, billing/EMR systems, and reporting tools
• Proven ability to reduce denials and rejections through trend analysis