"Alerted.org

Ready to help us transform healthcare? Bring your true colors to blue.

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.

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

LocationBoston, HinghamTime TypeFull time

Salary Range: $69,570.00 - $85,030.00

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 the confidence gap (https://www.theatlantic.com/magazine/archive/2014/05/the-confidence-gap/359815/) and imposter syndrome (https://www.braintreepayments.com/blog/overcoming-imposter-syndrome/) can 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 our Company Culture (https://careers.bluecrossma.org/us/en/culturepage) page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community (https://careers.bluecrossma.org/us/en/jointalentcommunity?applyType=JTC) to 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 (https://careers.bluecrossma.org/us/en/how-we-work) " Page.

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 Employer - veterans/disability. 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.