Quality Medical Auditor

BlueCross BlueShield of South Carolina•Columbia, SC

15h•Remote

About The Position

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! 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 is a remote position, Monday - Friday from 8:30am - 5pm.

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.