Florida Blue - Specialist IV Post-Payment Provider Audit Cln

About the position This is a senior-level technical position in the post-payment provider audit function intended to analyze assigned provider claims for risk of over and under payments to perform onsite and desk reviews in support of the business unit's objective to ensure all incorrectly billed and paid claims are adjusted accordingly to help control medical cost spend. This role requires a clinical certification to independently perform reviews of all assigned provider claims from a clinical, medical coding and provider billing perspective to ensure claims payment integrity. This will include reviews of corresponding medical records and clinical documentation to validate coding (specifically DRG) billing appropriateness. In addition, the role is responsible for ensuring claims are paid according to the provider and member contracts as well as ensuring that standard claims processing guidelines and billing procedures for each type of service and type of provider were followed. Additionally, this role is responsible for interacting directly with providers to coordinate onsite reviews and perform closing meetings with provider executives (CFOs, Managed Care VPs etc.) to present any findings that will result in claim adjustments. The essential functions listed represent the major duties of this role, additional duties may be assigned. Independently perform analysis of high risk claims on a post-payment basis utilizing clinical, coding and claims processing background to ensure claims are coded, billed and paid correctly. Leverage clinical and coding expertise to audit high risk claims for inappropriate application of associated Florida Blue policies and industry standard billing and care practices that may impact claims payment (e.g. MCG, LCD, Authorizations, Covered Benefits, Appropriateness of Service Setting). Specifically, independently request and review pertinent medical records to validate/invalidate potential issues identified on high risk claims. Determine claim level financial impact based on unique member benefits and provider contract terms and payment policies. Ensure claims processing compliance with overarching administrative regulations (Federal, State of Florida, BCBS Association etc.). Perform claims level analysis of appropriate provider coding and billing practices and/or guidelines. Plan and maintain an individual audit schedule through coordination and communication directly with provider personnel for onsite reviews as necessary. Thoroughly document identified issues to support claim adjustments (including supporting medical record, clinical or coding rationale). Lead onsite closing meetings with provider executives to communicate and gain agreement on audit findings prior to claim adjustments. Communicate large/impactful audit findings to appropriate internal parties as needed. Identify and document upstream process gaps driving incorrect payment for remediation and prevention.

Responsibilities

• Independently perform analysis of high risk claims on a post-payment basis utilizing clinical, coding and claims processing background to ensure claims are coded, billed and paid correctly.

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• Leverage clinical and coding expertise to audit high risk claims for inappropriate application of associated Florida Blue policies and industry standard billing and care practices that may impact claims payment.

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• Independently request and review pertinent medical records to validate/invalidate potential issues identified on high risk claims.

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• Determine claim level financial impact based on unique member benefits and provider contract terms and payment policies.

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• Ensure claims processing compliance with overarching administrative regulations (Federal, State of Florida, BCBS Association etc.).

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• Perform claims level analysis of appropriate provider coding and billing practices and/or guidelines.

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• Plan and maintain an individual audit schedule through coordination and communication directly with provider personnel for onsite reviews as necessary.

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• Thoroughly document identified issues to support claim adjustments (including supporting medical record, clinical or coding rationale).

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• Lead onsite closing meetings with provider executives to communicate and gain agreement on audit findings prior to claim adjustments.

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• Communicate large/impactful audit findings to appropriate internal parties as needed.

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• Identify and document upstream process gaps driving incorrect payment for remediation and prevention.

Requirements

• 5+ years related work experience with strong familiarity with ICD-9/10, DRG, CPT/HCPCS coding, or experience with multiple provider reimbursement and pricing methodologies.

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• Demonstrated proficient working knowledge of at least three of the following: medical terminology, claim audit procedures, provider contracts, claims processing procedures and guidelines, provider authorizations, provider billing, medical coding, concurrent review.

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• Related Bachelor's degree or additional related equivalent work experience.

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• Hold an active clinical certification (e.g. RN, LPN, PA).

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• Expected to obtain coding certification (CCS) within 18 months of hire, if not already obtained.

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• The ability to travel frequently.

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• Proficiency/experience working with tools/apps such as Diamond, Jiva, APT, EIP, Siebel, ICN, Quest, Contract Management System, Burgess, PPS Pricer, AHA coding Clinic, Encoder, Alineo.

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• Working knowledge of COB/OPL, Subrogation and Workers' Comp, standard claims adjustment processes and benefit plans.

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• Working knowledge of personal computer and related software (e.g., Excel, Microsoft Word).

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• Demonstrate flexibility in unplanned work and/or project support.

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• Excellent oral and written communications skills.

Nice-to-haves

• Strong analytics experience

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• Consulting experience

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• Masters Degree

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• Professional Medical Coding Certification (CPC, CCS, etc.)

Benefits

• Medical, dental, vision, life and global travel health insurance

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• Income protection benefits: life insurance, Short- and long-term disability programs

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• Leave programs to support personal circumstances

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• Retirement Savings Plan includes employer contribution and employer match

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• Paid time off, volunteer time off, and 11 holidays

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• Additional voluntary benefits available

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• A comprehensive wellness program

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