Vacancy expired!
Senior Recovery Auditor Full Time Job ID 892 Job DescriptionConduct complex, in-depth claim and data analysis of all claims payments, identifying trends and patterns to ascertain overpayment recovery potential. Ensure medical claims, medical records, and other documentation essential to claims submission and reimbursement are in compliance with state and federal guidelines, provider contracts, BCBSRI policy, national coding guidelines, and industry standards. Detect areas of billing inefficiencies, internal control weaknesses, and noncompliance and provide recommendations for corrective action plans.ESSENTIAL JOB FUNCTIONS:Conduct a thorough analysis of all medical claims for adherence to state and federal guidelines, provider contracts, BCBSRI policy, national coding guidelines, and industry standards.Review, research, and interpret medical record documentation, claims data, contractual guidelines, payment methodologies, and system adjudication to identify trends and patterns in complex claims payment data that result in recovery opportunities.Provide data, reimbursement analysis, and recommendations to management on all department non-compliant findings affecting reimbursement, including policy, contract issues, provider errors, pricing, systems, and claim processes.Perform audit peer review analysis for Audit Coordinator and Medical Claims Recovery Auditors periodically to ensure quality of results and consistency in content, analytics, and adherence to department policies and procedures.Develop written reports in accordance with reporting standards. Ensure that all audit findings, exceptions, and proposed adjustments to work papers are well defined and explained or included in reports.Provide guidance to auditors assigned to data. Provide on-the-job training and feedback throughout the reviews.Develop repayment plans with providers when necessary based on financial impact, scope of audit findings, and audit resolution.Manage appeals process with providers and third-party arbitrators. Forward pertinent documentation to arbitrator and advise provider of decision. The impact of the decision is reflected in the audit adjustment report and settlement process.Mentor less experienced staff.Lead department projects and initiatives.Perform other duties as assigned.QUALIFICATIONS: Minimum Education and Experience: Bachelor's degree in Business, Finance, Computer Science, Mathematics, Statistics, or related field; or an equivalent combination of education and experience.Coding certification (CPC, CCS, CPMA, or equivalent).Five-plus years of experience in medical claims review or claims processing.Five-plus years of experience in quantitative or statistical analysis (preferably in healthcare).Experience using PC SAS (preferably Enterprise Guide SAS), Crystal, and/or Business Objects.Proven analytic expertise using Microsoft Excel and database query capabilities and ability to evaluate data at all levels of detail.Preferred Education, Additional Qualifications, and Experience:Superior knowledge of diagnostic-related groups (DRG) and American Hospital Association Official Coding Guidelines.Familiarity and ability to interpret hospital/provider contracts.Familiarity with medical claims reimbursement.Financial/accounting methodology exposure.Required Knowledge, Skills, and/or Abilities:Knowledge of medical claims data.Knowledge of managed care practices.Knowledge of Correct Coding Initiative (CCI) guidelines.Demonstrated ability to constructively and sensitively provide feedback to providers regarding federal and state coding, medical documentation and compliance guidelines, audit results, and risk areas.Audit skills and the ability to interpret and apply federal and state regulations and coding and billing requirements.Demonstrated ability to review analytical, data, and audit findings to identify coding trends and risk areas.Ability to interpret contract reimbursement schedules and policies.Strategic and critical thinkin
