Senior Clinical Compliance Auditor

Blue Cross & Blue Shield of Mississippi • Flowood, MS

8d • Onsite

About The Position

At Blue Cross & Blue Shield of Mississippi, we’re not just about providing health insurance, we are creating a strong, supportive community which encourages every Mississippian to live their healthiest life. This mission requires a talented and motivated team with diverse sets of skills and experiences, aligned with the commitment of a healthy Mississippi. By combining strong financial stewardship with a focus on the Health & Wellness of Mississippians, we invest in programs, partnerships, and innovations which drive quality care, lower costs, and healthier lives. Join our team and start a meaningful career where your work supports better health outcomes for Mississippians every day. We are seeking a Senior Clinical Compliance Auditor to act as the primary clinical reviewer of analytical findings, complaints, formal referrals, and appeals related to the care or services provided by Network Hospitals, Providers, Pharmacies and other entities. This Senior Auditor reviews suspected instances of inappropriate billing of claims to Blue Cross & Blue Shield of Mississippi.

Requirements

• Bachelor’s degree in Nursing.
• Registered Nurse with an unrestricted license in the State of Mississippi.
• Three or more years of healthcare clinical experience.
• Knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases, 10th Revision (ICD-10) coding with applicable certification.
• Intermediate proficiency using Microsoft Office, specifically Excel.
• Interpersonal skills that guide group dynamics from leading meetings and articulate clinical findings objectively, to guiding sensitive discussions, building consensus and gaining buy-in without direct authority.
• Ability to author objective, legally sound, evidence-based reports, synthesizing complex clinical and legal jargon into plain language.
• Ability to work at a high degree of accuracy with information that is confidential in nature.
• Advanced organizational skills with the ability to prioritize competing tasks and perform them with accuracy simultaneously.

Nice To Haves

• Background in Utilization Management or Medical Review.
• Well-founded understanding of healthcare regulations of reimbursement and coding.

Responsibilities

• Conducts clinical reviews of medical records against guidelines, Provider contracts, Member Benefit Plan language and Medical Policy criteria.
• Gathers information from Members to aid in the review.
• Consults with Medical Director and Legal Operations with related questions during the auditing process.
• Reviews data analytical findings to identify aberrant patient care, utilization or billing practices.
• Determines and recommends appropriate interventions to address and resolve potential fraud, waste and abuse issues.
• Follows thorough clinical analysis, reports and recommends corrective action.
• Prepares written reports of audit outcome and conclusions with details of findings.

Benefits

• medical benefits
• 401(k)
• ample paid time off
• a schedule that supports true work/life balance
• comprehensive benefits package that is worth approximately one-third of the salary compensation

What This Job Offers

• Job Type: Full-time
• Career Level: Senior