Senior Clinical Compliance Auditor

Blue Cross & Blue Shield of Mississippi • Flowood, MS

37d

About The Position

The Senior Clinical Compliance Auditor serves as the primary clinical reviewer of data analysis findings, referrals, appeals and complaints related to Network Hospitals, Providers, Pharmacies, and other entities or programs suspected of inappropriate billing of claims to Blue Cross & Blue Shield of Mississippi. The incumbent is responsible for selecting, obtaining, coordinating, monitoring, and reviewing medical records and other relevant information for clinical and coding assessment and validation of related billing of services provided to Blue Cross Blue Shield Customers. The Senior Clinical Compliance Auditor collaborates with data analysts, compliance auditors, and the Medical Director to identify aberrant trends in patient care, utilization, and billing practices. The incumbent works with a multidisciplinary team to determine appropriate interventions to address and resolve identified issues. The incumbent prepares clear, detailed findings, reports, and recommendations for corrective action after thorough clinical analysis.

Requirements

• Bachelor’s degree in Nursing is required
• Registered Nurse with an unrestricted license in the state of Mississippi is required
• At least three years of healthcare clinical experience is required
• Knowledge CPT, HCPCS, ICD-10 coding with applicable certifications is required
• Intermediate knowledge of Microsoft Office, to include experience in Excel, is required
• Excellent oral and written communication skills with the ability to communicate a clear understanding of results of review finding are required
• Ability to work with a high degree of accuracy and attention to detail is required
• Must have the ability to handle information of a confidential nature
• Must possess excellent organizational skills, including the ability to prioritize multiple tasks and perform them both accurately and simultaneously
• Must possess strong interpersonal skills with the ability to build strong relationships to encourage trust and open communication

Nice To Haves

• Background in Utilization Management or Medical Review is preferred
• Strong knowledge of health care regulations related to reimbursement and coding is preferred.

Responsibilities

• primary clinical reviewer of data analysis findings, referrals, appeals and complaints
• selecting, obtaining, coordinating, monitoring, and reviewing medical records and other relevant information for clinical and coding assessment and validation
• collaborates with data analysts, compliance auditors, and the Medical Director to identify aberrant trends in patient care, utilization, and billing practices
• works with a multidisciplinary team to determine appropriate interventions to address and resolve identified issues
• prepares clear, detailed findings, reports, and recommendations for corrective action after thorough clinical analysis

Benefits

• We offer a comprehensive benefits package that is worth approximately one-third of the salary compensation.
• Our benefits program is among the best in the health care field.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Number of Employees: 1,001-5,000 employees