Blue Cross Blue Shield of Massachusetts
Prepayment Review Coding Specialist
Blue Cross Blue Shield of Massachusetts, Hingham, Massachusetts, us, 02043
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The position serves as a Prepayment Review Coding Specialist within the Fraud Investigation & Prevention Unit (“FIP”). The position will be a dedicated coding specialist reviewing medical records to identify instances of health care fraud, waste, and abuse and to facilitate accurate claim payments.
This role is open to candidates local to our Boston, MA or Hingham, MA office.
Your Day to Day
Utilize comprehensive knowledge, coding resources and reference materials of CPT, HCPCS, ICD-10, and modifiers to determine appropriate coding for complex claims
Perform complex retrospective and prepayment reviews of medical records and applicable documentation to identify potential fraud, waste, and abuse and inappropriate billing practices.
Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies.
Provide instructions to the claims operations department prepayment reviews to initiate claim adjustments
Provide coding consultation and education to all internal and external customers and providers
Follow HIPAA regulations and maintain a working knowledge of various laws, regulations and industry guidelines and legal requirements to ensure compliance with state and federal regulations
Consult investigators and data analysts to identify fraud and abuse by utilizing coding expertise to analyze patterns in billing activities
Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices
Responsible for contributing to the development and implementation of pre-payment review procedures and cases
Coordinate review processes with other departments to prevent inappropriate utilization of resources
Form recommendations regarding process improvements to eliminate provider fraud opportunities
Analyze, track and run financial savings reports by utilizing case management software
This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.
We’re Looking for:
The ability to handle complex and confidential matters in a professional manner
The ability to respond to demands and strict timelines in a fast-paced environment
A proficient understanding of medical coding and medical record reviews
Demonstrated analytical thinking skills
Knowledge of claims processing and adjudication by health insurers
Knowledge of health care delivery systems with an emphasis on medical and payment policy
Excellent written and oral communication skills
Knowledge of NASCO, Data Warehouse and EncoderPro is a plus
Proficiency at intermediate level with Microsoft Office- Word, Outlook, PowerPoint, Excel and Access
What You Bring:
CPC certification is required, CEMC is a plus
5+ years Claims experience is required
Investigative experience is a plus
What You’ll Gain: The opportunity to join the Fraud Investigation and Prevention Unit, which is a unique Unit within the Legal Department, that focuses on preventing fraud, waste, and abuse. The Unit includes a team of Senior managers, data analysts, fraud investigators, certified coders and medical providers.
Minimum Education Requirements: High school degree or equivalent required unless otherwise noted above
Location & Salary Boston, MA or Hingham, MA. Full time. Salary Range: $90,540.00 - $110,660.00
Variable pay is eligible. We offer a comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
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This role is open to candidates local to our Boston, MA or Hingham, MA office.
Your Day to Day
Utilize comprehensive knowledge, coding resources and reference materials of CPT, HCPCS, ICD-10, and modifiers to determine appropriate coding for complex claims
Perform complex retrospective and prepayment reviews of medical records and applicable documentation to identify potential fraud, waste, and abuse and inappropriate billing practices.
Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies.
Provide instructions to the claims operations department prepayment reviews to initiate claim adjustments
Provide coding consultation and education to all internal and external customers and providers
Follow HIPAA regulations and maintain a working knowledge of various laws, regulations and industry guidelines and legal requirements to ensure compliance with state and federal regulations
Consult investigators and data analysts to identify fraud and abuse by utilizing coding expertise to analyze patterns in billing activities
Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices
Responsible for contributing to the development and implementation of pre-payment review procedures and cases
Coordinate review processes with other departments to prevent inappropriate utilization of resources
Form recommendations regarding process improvements to eliminate provider fraud opportunities
Analyze, track and run financial savings reports by utilizing case management software
This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.
We’re Looking for:
The ability to handle complex and confidential matters in a professional manner
The ability to respond to demands and strict timelines in a fast-paced environment
A proficient understanding of medical coding and medical record reviews
Demonstrated analytical thinking skills
Knowledge of claims processing and adjudication by health insurers
Knowledge of health care delivery systems with an emphasis on medical and payment policy
Excellent written and oral communication skills
Knowledge of NASCO, Data Warehouse and EncoderPro is a plus
Proficiency at intermediate level with Microsoft Office- Word, Outlook, PowerPoint, Excel and Access
What You Bring:
CPC certification is required, CEMC is a plus
5+ years Claims experience is required
Investigative experience is a plus
What You’ll Gain: The opportunity to join the Fraud Investigation and Prevention Unit, which is a unique Unit within the Legal Department, that focuses on preventing fraud, waste, and abuse. The Unit includes a team of Senior managers, data analysts, fraud investigators, certified coders and medical providers.
Minimum Education Requirements: High school degree or equivalent required unless otherwise noted above
Location & Salary Boston, MA or Hingham, MA. Full time. Salary Range: $90,540.00 - $110,660.00
Variable pay is eligible. We offer a comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
#J-18808-Ljbffr