Blue Cross Blue Shield of Massachusetts Hospital Bill Auditor in Quincy, Massachusetts

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The Hospital Bill/ Outpatient 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 Hospital Bill 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 regards 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.

Responsibilities

  • Audits post pay 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.

  • Assesses medical necessity and/or clinical significance in addition to coding compliance and identifies opportunities for savings and cost avoidance.

  • Conducts provider appeals and consults with medical director when necessary.

  • Analyzes trends and billing behaviors of the audited facility and prepares educational 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.

Qualifications:

  • Ability to travel between provider organizations across Massachusetts required.

  • Strong organizational, project management, problem-solving and communication skills.

  • Ability to navigate and manage through difficult, complex conversations with positive outcomes.

  • Strong computer skills: – proficient in MS Word, Excel, PowerPoint and Outlook, familiarity with Electronic Medical Record systems.

  • Ability to work as part of a team with a positive attitude while also able to work independently.

  • Ability to travel within the state of Massachusetts for onsite audits on an as needed basis required.

  • E-working opportunities are available for Massachusetts residents. For those residing outside of Massachusetts, flexible working arrangements are available at the discretion of the leader.

Education/ Relevant Experience:

  • Active certified coder (RHIA, RHIT, CCS, and/or CPC) required.

  • Registered nurse (LPN, BSN and related advanced degree) or other relevant clinical experience is preferred.

  • Candidate will need to maintain active certification.

  • 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.

#LI-DNI

LocationQuincyTime TypeFull time

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.