Provider Audit Specialist

Southcarolinablues; Columbia (SC); Hybrid; USD 60,000 - 90,000; Full time

Benefits offered by this job

Subsidized health plans

401k with company match

Paid Time Off

Job summary

BlueCross BlueShield of South Carolina is seeking an experienced Audit Nurse to prepare for and perform institutional audits of provider billing, identify aberrant billings, and review all claims to ensure compliance and proper reimbursement.

The role requires an RN or LPN license with clinical nursing and medical audit experience, strong analytical skills, and the ability to work with hospital records and itemized bills.

Qualifications

• 3 years of clinical nursing and/or medical audit/investigations experience.
• 2 years of medical/surgical bedside experience.
• Knowledge of anatomy, physiology, and medical terminology; ability to verify medical records.

Responsibilities

• Conduct institutional reviews and audits of provider billing.
• Ensure timely completion of reviews and respond to inquiries.
• Review hospital itemized bills and medical records to verify charges.
• Identify high-dollar claims and coordinate onsite audits.
• Maintain audit files and refund tracking; report discrepancies to management.
• Notify management of potential fraud and advise on corrective actions.

Skills

Analytical thinking

Medical coding knowledge

Communication skills

Detail oriented

Time management

Education

Associate's in a related field

RN or LPN licensure

Tools

Microsoft Office

Audit software

Job description

Summary

Prepares for and performs institutional audits to assess appropriate provider billing and to identify any aberrant billings that may have an impact on reimbursement. Responsible for reviewing all aspects of claim processing to include fraudulent billing practices and to respond to providers on review/audit findings. Responsible for documenting cost savings related to reviews/audits. Identifies changes with hospital.

Why Join Us

Other companies come and go, but we’ve been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose

Prepares for and performs institutional audits to assess appropriate provider billing and to identify any aberrant billings that may have an impact on reimbursement. Responsible for reviewing all aspects of claim processing to include fraudulent billing practices and to respond to providers on review/audit findings. Responsible for documenting cost savings related to reviews/audits. Identifies changes with hospital.

Location

This position is a full-time role, between the hours of 7:30am and 5pm. You will work an 8-hour shift during that time. This is located at 2401 Faraway Drive Columbia, SC 29223. There is the potential for hybrid work after the training time period.

Sponsorship

This position is not eligible for sponsorship now or in the future.

What You’ll Do

Conducts institutional reviews and/or audits to assess appropriate provider billing and to identify any aberrant billings that have an impact on reimbursement. Responsible for timely completion of reviews/audits and responses to inquiries. Ensures appropriateness of what has been billed and should be allowed by reviewing hospital itemized bills and hospital medical record to determine services/charges that are and are not covered and/or allowed to be billed separately. Researches the claim system to identify other claims related to the one being reviewed/audited. Responsible for timely review of high dollar claims to minimize the time between receipt of the claim and completion of the high dollar review so the claim can be paid. Some day and overnight travel to hospital locations throughout the state of South Carolina may be needed in order to perform and complete onsite audits. Analyzes audit findings and completes letters and reports providing the discrepancies between the medical records and the itemized bill to the provider. Responsible for notifying and providing the claim operation departments with high dollar review findings so the claim can be processed for payment. Completes and maintains audit files and internal tracking tools for each audit. Responsible for ensuring that overpayments to the provider have been recovered through claim reviews/processing and use of internal refund tracking systems. Responds to provider inquiries related to audit findings. Requests and analyzes reports on institutional providers to identify claims appropriate to audit after payment of the claim. Follows departmental procedures and guidelines to ensure validity of claims selected to audit. Coordinates with providers to determine an agreed upon date that the onsite audit evaluation can be performed, ensuring timely scheduling of the audit. Assists with and provides feedback on department policies/procedures throughout the audit/review processes. Notifies management of inconsistencies and/or changes in billing practices to rule out possible fraud and abuse. Makes recommendations to improve department productivity, cost effectiveness, and timeliness. Participates in department activities: committees, staff meetings, educational opportunities, etc.

To Qualify For This Position, You’ll Need The Following

Required Education

Associate's in a job related field

Degree Equivalency

RN licensure or LPN licensure with additional one year of clinical nursing experience (the additional experience cannot be included in the required work experience).

Required Work Experience

3 years of clinical nursing and/or medical audit/investigations experience to include 2 years of medical/surgical bedside experience.

Required Skills and Abilities

Knowledge of anatomy and physiology, disease processes, medical terminology, and patient care practices in order to verify accuracy of medical records. Ability to interpret medical records and itemized bills. Familiar with hospital billing knowledge and knowledge of revenue, CPT, HCPCS, medical coding, etc. Ability to communicate verbally and in writing to all levels of the organization and externally. Excellent analytical or critical thinking and problem-solving capabilities with attention to detail. Ability to make sound decisions. Ability to successfully complete multiple tasks simultaneously. Ability to work with minimal supervision in a fast-paced environment. Ability to make appropriate decisions on claims reviewed/audited in a timely and accurate manner. Good time management and organizational skills. Ability to handle confidential or sensitive information with discretion. Detail oriented.

Required Software and Tools

Microsoft Office.

Required Licenses and Certificates

Active, unrestricted RN or LPN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN or LPN license as defined by the Nurse Licensure Compact (NLC).

Preferred Skills and Abilities

Knowledge of hospital and physician audit principles, procedures, and reimbursement. Knowledge of group and/or hospital contracts or the ability to acquire. Good team building and leadership skills. Knowledge of patient care practices, anatomy, and disease processes to verify accuracy of medical records. Knowledge of hospital and physician audit procedures and requirements.

Preferred Software and Tools

Working knowledge of Microsoft Office, especially Word, Excel and Access; working knowledge of Adobe (or the ability to acquire). Previous experience using, or the ability to learn, the BCBSSC system to access necessary information.

Our Comprehensive Benefits Package Includes The Following

We offer our employees great benefits and rewards. You will be eligible to participate in our benefits program the first of the month following 28 days of employment.

• 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

What We Can Do for You

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

Veterans Welcome

BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy‑related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email [e-mail] or call 800‑288‑2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case‑by‑case basis. We participate in E‑Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.