https://www.linkedin.com/jobs/view/581525177/
BCBSMA POSITION DESCRIPTION
Position Title: Provider Auditor DRG Hospitals
Department/Division: Recoveries and Provider Audit /IT and Operations
Reports to: Manager, Provider Audit
Location: Quincy
Position Summary
The Provider Auditor for post-pay review is responsible for verifying 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. Serving as one of the faces of the Company to provider organizations across Massachusetts, the Provider Auditor strives to improve correct claims payments in order to contribute to the reduction of medical expense. The individual will be a subject matter expert in regards to coding and billing. S/he will also respond to inquiries from a wide variety of internal and external stakeholders. S/he will collaborate with a variety of business units including Fraud and Abuse, Health and Medical Management, Network Management and our external provider community. 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.
Responsibilities
Conduct Diagnosis Related Grouper Validation (DRG) audits to verify the accuracy of claims reimbursement by applying National Healthcare Billing Audit standards, Coding Clinic guidelines published by the American Hospital Association, and the Plans agreements including published policies.
Select claims samples for medical record reviews in accordance with pre-selection criteria, billing trends, and supporting documentation.
Monitor existing/emerging trends and keep relevant stakeholders informed of risk areas and concerns that may require additional attention.
Act as a subject matter expert with internal and external stakeholders in reference to coding, billing practices, and accuracy of assigned ICD-10codes.
Educate on post audit findings and close audits timely using audit program databases that incorporate 3M software.
Identify potential quality of care issues and service or treatment delays. Make referrals for follow-up as necessary.
Identify possible fraud and abuse, document billing errors, and benefit cost management and savings opportunities.
Actively participate in internal/external meetings, training activities and other cost and trend initiatives.
Identify and pursue new opportunities for cost avoidance savings that contribute to the company’s annual financial and service targets.
Meet deadlines and commitments by tightly managing deliverables, coordinating matrixed inputs and ensuring all tasks are performed to bring projects to timely closure.
Represent department on cross functional workgroups and projects as needed.
Conduct audits remotely as well as onsite for certain hospitals.
Qualifications
Active Certified coder (RHIA, RHIT, or CCS ) required candidate would need to maintain active certification.
In-depth knowledge of and ability to interpret APR-DRG, HCPCS, CPT, ICD10-CM diagnosis and procedure codes and Plan benefit designs required.
Ability to travel for onsite audits on an as needed basis required.
3-5 years experience reviewing 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.
Ability to travel between provider organizations across Massachusetts required.
Strong organizational, project management, problem-solving and communication skills.