Blue Cross and Blue Shield of Massachusetts, Inc.
Professional Auditor
Blue Cross and Blue Shield of Massachusetts, Inc., Boston, Massachusetts, us, 02298
About the Role:
The Professional Auditor is responsible for post-pay review to verify the accuracy of claims reimbursement, clinical significance, coding, and billing in accordance with the Plans' provider agreements and the National Healthcare guidelines. The Professional Auditor helps improve clinical outcomes and quality of care, to reduce medical expenses by conducting audits. The Professional Auditor will be a subject matter expert regarding coding and billing. The Professional Auditor, under the direction of Audit manager, will collaborate with a variety of business units including Fraud and Abuse, Medical Management, Medical Directors, Network Management, and our external Provider community. Your Day to Day:
Perform post-pay audits on hospital bills and medical records to assure all services and charges are supported by clinical documentation. Assures 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. We're Looking For:
BS/BA Degree or comparable work experience Active certified coder (RHIA, RHIT, CCS-P, CCS, and/or CPC) required; CPMA, COC, CPB certifications a plus. 1-3 years' experience in medical coding and auditing - experience in medical billing a plus Experience reviewing medical record documentation for compliance of billing and coding for Outpatient/ASC claims preferred Microsoft Office products a plus In-depth knowledge CPT, HCPCS, and ICD-10-CM Working knowledge of electronic medical records systems Ability to work as part of a team and independently 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. What You Bring:
Character - Demonstrates unquestionable integrity in every aspect of work and dealing with others; Consistently models desired behaviors and values established by the company; Respect diversity of perspective in discussions and demonstrates an inclusive style; Demonstrates concerns for job safety for self and others. Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; Supports organization's goals and values; Supports affirmative action and respects diversity. Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Completes tasks on time or notifies appropriate person with an alternate plan. What You'll Gain:
This is a high-profile position with visibility into all levels of the organization. This position will work with multiple other areas including High-Cost Claims, Payment Policy Strategy, Data Mining Audit, Facility Reimbursement, and Fraud Investigation and Prevention. 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. We are an equal opportunity employer and welcome applications from diverse candidates. We are committed to investing in your development and providing the necessary resources to enable your success.
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The Professional Auditor is responsible for post-pay review to verify the accuracy of claims reimbursement, clinical significance, coding, and billing in accordance with the Plans' provider agreements and the National Healthcare guidelines. The Professional Auditor helps improve clinical outcomes and quality of care, to reduce medical expenses by conducting audits. The Professional Auditor will be a subject matter expert regarding coding and billing. The Professional Auditor, under the direction of Audit manager, will collaborate with a variety of business units including Fraud and Abuse, Medical Management, Medical Directors, Network Management, and our external Provider community. Your Day to Day:
Perform post-pay audits on hospital bills and medical records to assure all services and charges are supported by clinical documentation. Assures 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. We're Looking For:
BS/BA Degree or comparable work experience Active certified coder (RHIA, RHIT, CCS-P, CCS, and/or CPC) required; CPMA, COC, CPB certifications a plus. 1-3 years' experience in medical coding and auditing - experience in medical billing a plus Experience reviewing medical record documentation for compliance of billing and coding for Outpatient/ASC claims preferred Microsoft Office products a plus In-depth knowledge CPT, HCPCS, and ICD-10-CM Working knowledge of electronic medical records systems Ability to work as part of a team and independently 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. What You Bring:
Character - Demonstrates unquestionable integrity in every aspect of work and dealing with others; Consistently models desired behaviors and values established by the company; Respect diversity of perspective in discussions and demonstrates an inclusive style; Demonstrates concerns for job safety for self and others. Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; Supports organization's goals and values; Supports affirmative action and respects diversity. Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Completes tasks on time or notifies appropriate person with an alternate plan. What You'll Gain:
This is a high-profile position with visibility into all levels of the organization. This position will work with multiple other areas including High-Cost Claims, Payment Policy Strategy, Data Mining Audit, Facility Reimbursement, and Fraud Investigation and Prevention. 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. We are an equal opportunity employer and welcome applications from diverse candidates. We are committed to investing in your development and providing the necessary resources to enable your success.
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