Provider Audit Specialist

BlueCross BlueShield of South Carolina•Columbia, SC

2d•Hybrid

About The Position

Prepares for and performs institutional audits to assess appropriate provider billing and to identify any aberrant billings that may have an impact on reimbursement. Responsible for reviewing all aspects of claim processing to include fraudulent billing practices and to respond to providers on review/audit findings. Responsible for documenting cost savings related to reviews/audits. Identifies changes with hospital. BlueCross BlueShield of South Carolina has been part of the national landscape for more than seven decades, with its roots firmly embedded in the South Carolina community. It is the largest insurance company in South Carolina and a leading administrator of government contracts, operating one of the most sophisticated data processing centers in the Southeast. The company has a diverse family of subsidiary companies, allowing it to build on various business strengths and deliver outstanding service to its customers.

Requirements

Associate's in a job related field
RN licensure or LPN licensure with additional one year of clinical nursing experience (the additional experience cannot be included in the required work experience).
3 years of clinical nursing and/or medical audit/investigations experience to include 2 years of medical/surgical bedside experience.
Knowledge of anatomy and physiology, disease processes, medical terminology, and patient care practices in order to verify accuracy of medical records.
Ability to interpret medical records and itemized bills.
Familiar with hospital billing knowledge and knowledge of revenue, CPT, HCPCS, medical coding, etc.
Ability to communicate verbally and in writing to all levels of the organization and externally.
Excellent analytical or critical thinking and problem-solving capabilities with attention to detail.
Ability to make sound decisions.
Ability to successfully complete multiple tasks simultaneously.
Ability to work with minimal supervision in a fast-paced environment.
Ability to make appropriate decisions on claims reviewed/audited in a timely and accurate manner.
Good time management and organizational skills.
Ability to handle confidential or sensitive information with discretion.
Detail oriented.
Microsoft Office.
Active, unrestricted RN or LPN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN or LPN license as defined by the Nurse Licensure Compact (NLC).

Nice To Haves

Knowledge of hospital and physician audit principles, procedures, and reimbursement.
Knowledge of group and/or hospital contracts or the ability to acquire.
Good team building and leadership skills.
Knowledge of patient care practices, anatomy, and disease processes to verify accuracy of medical records.
Knowledge of hospital and physician audit procedures and requirements.
Working knowledge of Microsoft Office, especially Word, Excel and Access; working knowledge of Adobe (or the ability to acquire).
Previous experience using, or the ability to learn, the BCBSSC system to access necessary information.

Responsibilities

Conducts institutional reviews and/or audits to assess appropriate provider billing and to identify any aberrant billings that have an impact on reimbursement.
Responsible for timely completion of reviews/audits and responses to inquiries.
Ensures appropriateness of what has been billed and should be allowed by reviewing hospital itemized bills and hospital medical record to determine services/charges that are and are not covered and/or allowed to be billed separately.
Researches the claim system to identify other claims related to the one being reviewed/audited.
Responsible for timely review of high dollar claims to minimize the time between receipt of the claim and completion of the high dollar review so the claim can be paid.
Analyzes audit findings and completes letters and reports providing the discrepancies between the medical records and the itemized bill to the provider.
Responsible for notifying and providing the claim operation departments with high dollar review findings so the claim can be processed for payment.
Completes and maintains audit files and internal tracking tools for each audit.
Responsible for ensuring that overpayments to the provider have been recovered through claim reviews/processing and use of internal refund tracking systems.
Responds to provider inquiries related to audit findings.
Requests and analyzes reports on institutional providers to identify claims appropriate to audit after payment of the claim.
Follows departmental procedures and guidelines to ensure validity of claims selected to audit.
Coordinates with providers to determine an agreed upon date that the onsite audit evaluation can be performed, ensuring timely scheduling of the audit.
Assists with and provides feedback on department policies/procedures throughout the audit/review processes.
Notifies management of inconsistencies and/or changes in billing practices to rule out possible fraud and abuse.
Makes recommendations to improve department productivity, cost effectiveness, and timeliness.
Participates in department activities: committees, staff meetings, educational opportunities, etc.