[Hiring] Quality Medical Auditor @BlueCross BlueShield of South Carolina

Role Description

Performs validation reviews of Diagnosis Related Groups (DRG), Ambulatory Procedure Codes (APC), and Never Events (serious, preventable medical errors) 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.

What You’ll Do

• 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.

Qualifications

• 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, organizational, customer service, and analytical or critical thinking skills.
• Good judgment.
• Ability to handle confidential or sensitive information with discretion.
• Extensive medical records and coding knowledge.
• Working knowledge of contract evaluations, claims processing and adjudication practices.

Requirements

• 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 and in the state of hire OR 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.