Professional Auditor

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.

This role is eligible for the following personas: [E-Worker, Mobile, and Resident].

Your Day to Day:

Preform 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.

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:

• 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.

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

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.

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.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.