Sr Professional Auditor

Blue Cross Blue Shield of Massachusetts • Hingham, MA

1d

About The Position

About the Role: The Sr. Professional Auditor is responsible to verify the accuracy of claims reimbursement, clinical significance, medical necessity, coding, and billing in accordance with the Plans’ provider agreements and the National Healthcare Billing Audit guidelines. Often serving as one of the “faces” of the Company to provider organizations across Massachusetts, the Sr. Professional Auditor helps to improve clinical outcomes and quality of care, to reduce medical expense by conducting audits and often reviewing the results with the providers. The individual will be a subject matter expert in regard to coding and billing. S/he will also respond to inquiries from a wide variety of internal and external stakeholders and for providing claims information, data, claim summaries, and analysis. S/he will collaborate with a variety of business units including Fraud and Abuse, Health and Medical Management (including Medical Directors), Network Management and our external Provider community. Therefore, the successful candidate must be capable of building and maintaining strong working relationships with key internal and external constituents and working effectively in a matrixed environment. This role is eligible for the following personas: [Flex].

Requirements

• BS/BA degree or comparable work experience
• Active certified coder (RHIA, RHIT, CCS-P, CCS, and/or CPC) required
• 3-5+ years’ experience reviewing, coding, and/or auditing medical records, working in a health plan or hospital environment or other hands-on work with complex medical and billing information preferred.
• Experience reviewing medical record documentation for compliance of billing and coding for Outpatient claims preferred.
• Microsoft Office products a plus
• In-depth knowledge CPT, HCPCS, and ICD-10-CM
• Working knowledge of electronic medical records systems
• Strong organizational, project management, problem-solving and communication skills.
• Ability to navigate and manage through difficult, complex conversations with positive outcomes.
• Strong technical skills with ability to learn audit platforms such as STARRS, NASCO,
• Ability to work as part of a team with a positive attitude while also able to work independently.

Nice To Haves

• CPMA, COC, CPB certifications a plus.
• Registered nurse (LPN, BSN and related advanced degree) or other relevant clinical experience is preferred.

Responsibilities

• Preform post pay audits professional medical records to ensure all services and charges are supported by clinical documentation.
• Ensures appropriate application of BCBSMA guidelines, policy and procedures, and claims system edits.
• Conducts provider appeals and consults with medical director when necessary.
• Analyzes trends and billing behaviors of the audited facility and prepares feedback with audit findings.
• Monitors and identifies existing & emerging issues/trends and keeps relevant stakeholders informed of assessed levels of risk.
• Identifies potential quality of care issues and potential fraud, waste, or abuse.
• Makes referrals for follow-up as necessary.
• Actively participates in internal/external meetings, training activities and other cost and trend initiatives.
• Pursues new opportunities for cost avoidance savings that contribute to the company's annual financial and service targets.
• Meets deadlines and commitments by tightly managing deliverables, coordinating matrixed inputs and ensures all tasks are performed to bring projects to timely closure.
• Represents department on cross functional workgroups and projects as needed.
• Consults with internal departments regarding billing, coding, and medical record review as needed.

Benefits

• We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

What This Job Offers

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