Quality Medical Auditor
BlueCross BlueShield of South Carolina
full-time
Posted on:
Location Type: Remote
Location: South Carolina • United States
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About the role
- Performs validation reviews of Diagnosis Related Groups (DRG), Ambulatory Procedure Codes (APC), and Never Events for all lines of business
- Coordinates rate adjustments with claims areas
- Provides monthly and quarterly reports outlining trends
- Serves as a resource in resolving coding issues
- Coordinates HIPAA and legal records requests for all areas of Healthcare Services and the Legal Department
- Determines methodology to identify cases for validation review
- Conducts validation reviews/coordinates rates adjustments with appropriate claims area
- Creates monthly/quarterly reports to present to each line of business providing information on records review, outcomes, trends, and savings that directly impact medical costs and contracting rates
- Manages records retrieval, release, HIPAA compliance, and all aspects of document management
- Serves as expert resource on methodology and procedures for medical records and coding issues
Requirements
- Associates in a job-related field
- 2 years job related work experience
- 3 years medical record management to include coding and validation review experience
- Excellent verbal and written communication skills
- Excellent organizational skills
- Excellent customer service skills
- Excellent analytical or critical thinking skills
- Good judgment
- Extensive medical records and coding knowledge
- Working knowledge of contract evaluations, claims processing and adjudication practices
- Registered health information administrator (RHIA) OR Registered health information technician (RHIT) OR Certified Professional Coder (CPC) OR Certified Inpatient Coder (CIC) OR Certified Professional Medical Auditor (CPMA) OR, active, unrestricted RN licensure from the United States
- active compact multi-state unrestricted RN license as defined by Nurse Licensure Compact (NLC)
Benefits
- Subsidized health plans
- Dental and vision coverage
- 401k retirement savings plan with company match
- Life Insurance
- Paid Time Off (PTO)
- On-site cafeterias and fitness centers in major locations
- Education Assistance
- Service Recognition
- National discounts to movies, theaters, zoos, theme parks and more
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
codingvalidation reviewmedical record managementclaims processingadjudication practicesmethodology developmentdata analysisreport creationHIPAA compliancedocument management
Soft Skills
verbal communicationwritten communicationorganizational skillscustomer serviceanalytical skillscritical thinkinggood judgment
Certifications
Registered Health Information Administrator (RHIA)Registered Health Information Technician (RHIT)Certified Professional Coder (CPC)Certified Inpatient Coder (CIC)Certified Professional Medical Auditor (CPMA)active RN licensurecompact multi-state RN license