Quality Medical Auditor - Coding Specialist

BlueCross BlueShield of South Carolina•Columbia, SC

11d•Hybrid

About The Position

Position Purpose: Performs validation reviews of Diagnosis Related Groups (DRG), Adaptive Predictive Coding (APC), and Never Events (inexcusable outcomes in a healthcare setting) for all lines of business. Coordinates rate adjustments with claims areas. Provides monthly and quarterly reports outlining trends. Serves as a resource in resolving coding issues. Coordinates HIPAA and legal records requests for all areas of Healthcare Services and the Legal Department. Location: This role is located at 2401 Faraway Drive, Columbia, SC 29229. There is the potential for remote work.

Requirements

Associates in a job-related field.
2 years job related work experience.
3 years medical record management to include coding and validation review experience.
Excellent verbal and written communication, organizational, customer service, and analytical or critical thinking skills.
Good judgment.
Ability to handle confidential or sensitive information with discretion.
Extensive medical records and coding knowledge.
Working knowledge of contract evaluations, claims processing and adjudication practices.
Registered health information administrator (RHIA) OR Registered health information technician (RHIT) OR Certified Professional Coder (CPC) OR Certified Inpatient Coder (CIC) or Certified Professional Medical Auditor (CPMA) OR, active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multi-state unrestricted RN license as defined by Nurse Licensure Compact (NLC).

Responsibilities

Determines methodology to identify cases for validation review.
Conducts validation reviews/coordinates rates adjustments with appropriate claims area.
Creates monthly/quarterly reports to present to each line of business providing information on records review, outcomes, trends, and savings that directly impact medical costs and contracting rates.
Manages records retrieval, release, HIPAA compliance, and all aspects of document management.
Serves as expert resource on methodology and procedures for medical records and coding issues.