Description

The Facility Audit Department at BCBST is searching for a talented Coding Auditor to join our dynamic team in performing detailed claims payment quality reviews and coding compliance audits. This role is essential in reviewing hospital claims to ensure appropriate reimbursement, as well as compliance with contracts, regulatory requirements, and BCBST guidelines. A unique aspect of this position is providing educational feedback and reports to TN facilities based on audit findings. While travel is not currently required, there may be rare occasions when traveling to a TN facility for an audit becomes necessary, so we’re seeking candidates who reside in Tennessee or contiguous counties.

The ideal candidate will bring a Bachelor’s degree or equivalent experience, together with at least two years of facility inpatient or outpatient coding and auditing experience, or reimbursement experience in a payer environment. An active AHIMA certification is required, or the willingness to obtain CCS within a year of hire. Experience with Facets, Care Advance, and other internal systems is highly valued. We are especially excited to find someone eager to use Enterprise-AI approved tools in their work, helping us uncover opportunities for improvement and drive greater efficiencies.  

Job Responsibilities

Communicating audit results to appropriate parties; recommending corrective course of action.
Reviewing the claims materials and medical record information submitted and assessing accuracy of provider submitted claims.
Planning and conducting investigations for certain claims; identifying potential subrogation or fraud and engaging special investigate unit as needed.
Documenting audit results and supporting the development of audit policies and procedures.

Requirements

Education

Bachelor's Degree or equivalent work experience required. Equivalent experience is defined as 4 years of professional work experience in a corporate environment.
 

Experience

2 years - Professional/ancillary or facility inpatient/outpatient coding and/or auditing experience in an applicable setting.
 

Skills\Certifications

Current AHIMA or AAPC coding certification preferably CPC or CCS, will consider candidate who does not currently hold certification with the condition that the incumbent will successfully complete the certification exam within 12 months of employment.
Ability to handle confidential and sensitive information.
Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Proficient oral and written communication skills
Proficient interpersonal and organizational skills
Capacity to solve problems and manage multiple assignments with critical deadlines
Proven decision making and problem solving skills
Strong analytical skills
Positive attitude, self-driven, engaging, proactive, results drive
Solid knowledge and understanding of provider reimbursement methodologies, ICD-10 CM/PCS, CPT, HCPCS and applicable billing requirements (CMS-1500 or UB-04).
Must have the ability to apply the appropriate contract language, billing guidelines, medical and reimbursement policies
Must deal with continual resistance of providers to the audit and recovery process conducted by BCBST