Coding Auditor

📋 Description

• • Are you a meticulous professional with a passion for ensuring accuracy and compliance within the healthcare industry? BlueCross BlueShield of Tennessee (BCBST) is seeking a dedicated Coding Auditor to join our dynamic Professional and Ancillary Audit Department. This pivotal role is instrumental in upholding the integrity of our claims processing by conducting thorough quality reviews and clinical coding compliance audits. You will be at the forefront of identifying areas for enhancement, ensuring that our operational processes consistently adhere to the most stringent industry standards and regulatory requirements.
• • As a Coding Auditor, your primary responsibility will be to meticulously review claims materials and associated medical record information. This involves a deep dive into the submitted documentation to assess the accuracy of provider-submitted claims, ensuring they align with established coding guidelines and medical necessity.
• • A critical aspect of this role involves planning and executing investigations for specific claims. This proactive approach allows for the early identification of potential subrogation opportunities or instances of suspected fraud. When such cases are identified, you will be responsible for engaging the appropriate internal teams, such as the Special Investigations Unit, to ensure a comprehensive and compliant resolution.
• • You will play a key role in communicating audit findings to relevant stakeholders. This includes presenting clear, concise reports on audit results and providing actionable recommendations for corrective courses of action. Your insights will directly contribute to improving coding practices and reducing claim denials or overpayments.
• • The role also involves documenting all audit findings meticulously. This detailed record-keeping is essential for tracking trends, supporting the development and refinement of audit policies and procedures, and ensuring a robust audit trail for compliance purposes.
• • We are looking for an individual who is not only proficient in coding and auditing but also embraces innovation. This position offers the exciting opportunity to leverage Enterprise-AI approved tools in your daily workflow, enhancing efficiency and analytical capabilities.
• • You will be expected to work independently, demonstrating a high degree of self-direction and initiative, while also being a collaborative team player capable of sharing responsibilities and accountability.
• • The ability to handle confidential and sensitive information with the utmost discretion is paramount, given the nature of the data reviewed.
• • You will need to possess strong analytical skills to interpret complex medical records, coding rules, and reimbursement policies. This includes a solid understanding of provider reimbursement methodologies, ICD-10 CM/PCS, CPT, HCPCS, and applicable billing requirements (CMS-1500 or UB-04).
• • Applying the appropriate contract language, billing guidelines, medical policies, and reimbursement policies to specific audit scenarios will be a core function of your role.
• • A significant part of this role involves navigating and managing provider interactions, which may include dealing with resistance to the audit and recovery process. Your professionalism and communication skills will be crucial in these situations.
• • This position offers a unique opportunity to contribute to the elevated quality and compliance of healthcare services provided by BCBST, making a tangible impact on patient care and financial integrity.
• • You will be responsible for maintaining up-to-date knowledge of all relevant coding standards, regulatory changes, and industry best practices to ensure ongoing compliance and accuracy in all audit activities.
• • The role requires a proactive approach to problem-solving, identifying potential issues before they escalate and developing effective solutions.
• • You will contribute to the continuous improvement of the audit department's processes and methodologies, sharing best practices and insights with colleagues.
• • This is an excellent opportunity for a detail-oriented individual to grow their career in healthcare auditing within a reputable organization committed to excellence.