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The Provider Audit Consultant for post-pay review 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 Provider 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.
Perform post-pay audits by conducting medical record reviews to assure all services and charges are supported by clinical documentation, national coding guidelines, BCBSMA contracts, and administrative policies.
Consult as a subject matter expert with internal and external stakeholders in reference to coding, billing practices, behaviors, trends, and findings/appeals.
Responsible for the first and second level appeals, collaborate with medical director, and deliver final determination to providers
Monitor existing & emerging issues/trends and keep relevant stakeholders informed of risk areas and concerns that may require additional attention.
Abstract clinical information from health management systems and claims to provide a clinical summary report of a member’s course of illness and history of service utilization and costs incurred.
Accountable for identifying potential quality of care issues and service or treatment delays.
Flag potential leads to Fraud Investigation and Prevention unit, document billing errors, and benefit cost management and savings opportunities.
Monitor output from audits to ensure accuracy of system outputs. Enhance the integrity of corporate and health management procedures by identifying situations that do not support effective cost or quality efforts.
Coordinate claim finding issues with medical, pharmacy, contractual and claims inquiries and provide interpretation of medical policy, contracts and benefits.
Interact with multiple levels of provider leadership and present audit results at close meetings as well as lead communications with senior management.
Assist in the development and implementation of continuous process/policy improvements.
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.
Exercise considerable latitude in determining objectives and approaches to assignment.
Serve as the primary point of contact and external-facing representative of the company at meetings, conferences, and AHIMA/AAPC sponsored events.
Certified coder (CPC/CCS+) required.
Registered nurse or LPN, BSN, BA, or BS and/or related advanced degree preferred but not required.
Exceptional organizational, project management, problem-solving and communication skills.
Ability to navigate and manage through difficult, complex conversations with positive outcomes.
The ability to successfully manage multiple projects and competing priorities simultaneously.
In-depth knowledge of APR-DRG, HCPCS, CPT, ICD10-CM diagnosis and ICD-10-PCS procedure codes and Plan benefit designs.
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.
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 between provider organizations across Massachusetts.
This position offer remote access (e-working) options.