Senior Clinical Compliance Auditor

Blue Cross & Blue Shield of Mississippi; Flowood (MS); On-site; USD 85,000 - 120,000; Full time

Job summary

Blue Cross & Blue Shield of Mississippi is seeking a Senior Clinical Compliance Auditor to act as the primary clinical reviewer of findings, complaints, and appeals related to care provided by network hospitals, providers and pharmacies. You will assess billing and coding accuracy, ensure compliance, and prepare objective audit reports.

The ideal candidate has a nursing degree, an active Mississippi RN license, 3+ years of clinical healthcare experience, and strong knowledge of CPT/HCPCS/ICD-10

Qualifications

• Bachelor’s degree in Nursing.
• Registered Nurse with an unrestricted Mississippi license.
• Three+ years of healthcare clinical experience.
• CPT/HCPCS/ICD-10 coding knowledge with applicable certification.
• Proficient with Microsoft Excel and basic Office tools.

Responsibilities

• Conduct clinical reviews of medical records against guidelines, contracts, and policy language.
• Consult with Medical Director and Legal Operations during audits.
• Review data analyses to identify aberrant patient care, utilization or billing practices.
• Determine and recommend interventions to address potential fraud, waste and abuse.
• Prepare written reports detailing audit findings, conclusions and recommendations.

Skills

Nursing

RN license (Mississippi)

Healthcare experience

CPT/HCPCS/ICD-10 knowledge

Microsoft Excel

Communication & reporting

Education

Bachelor’s degree in Nursing

Tools

Microsoft Office

Job description

Healthy Careers Start Here

Be part of a vision for a healthier Mississippi as a Senior Clinical Compliance Auditor. At Blue Cross & Blue Shield of Mississippi, we’re not just about providing health insurance, we are creating a strong, supportive community which encourages every Mississippian to live their healthiest life. This mission requires a talented and motivated team with diverse sets of skills and experiences, aligned with the commitment of a healthy Mississippi. By combining strong financial stewardship with a focus on the Health & Wellness of Mississippians, we invest in programs, partnerships, and innovations which drive quality care, lower costs, and healthier lives. Join our team and start a meaningful career where your work supports better health outcomes for Mississippians every day. We are seeking a Senior Clinical Compliance Auditor to act as the primary clinical reviewer of analytical findings, complaints, formal referrals, and appeals related to the care or services provided by Network Hospitals, Providers, Pharmacies and other entities. This Senior Auditor reviews suspected instances of inappropriate billing of claims to Blue Cross & Blue Shield of Mississippi.

What You’ll Do

• Conducts clinical reviews of medical records against guidelines, Provider contracts, Member Benefit Plan language and Medical Policy criteria. Gathers information from Members to aid in the review.
• Consults with Medical Director and Legal Operations with related questions during the auditing process.
• Reviews data analytical findings to identify aberrant patient care, utilization or billing practices.
• Determines and recommends appropriate interventions to address and resolve potential fraud, waste and abuse issues.
• Follows thorough clinical analysis, reports and recommends corrective action.
• Prepares written reports of audit outcome and conclusions with details of findings.

Job-Specific Requirements

• Bachelor’s degree in Nursing.
• Registered Nurse with an unrestricted license in the State of Mississippi.
• Three or more years of healthcare clinical experience.
• Knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases, 10th Revision (ICD-10) coding with applicable certification.
• Intermediate proficiency using Microsoft Office, specifically Excel.
• Interpersonal skills that guide group dynamics from leading meetings and articulate clinical findings objectively, to guiding sensitive discussions, building consensus and gaining buy-in without direct authority.
• Ability to author objective, legally sound, evidence-based reports, synthesizing complex clinical and legal jargon into plain language.
• Ability to work at a high degree of accuracy with information that is confidential in nature.
• Advanced organizational skills with the ability to prioritize competing tasks and perform them with accuracy simultaneously.

Preferred Include

• Background in Utilization Management or Medical Review.
• Well-founded understanding of healthcare regulations of reimbursement and coding.

Why Join Us

• Purpose-Driven Work: Make a meaningful impact on the Health & Wellness of our Members.
• Learning & Development: Build foundational knowledge in finance and investment accounting.
• Career Growth: Clear pathways to grow your career where your skills flourish, including Treasury, Financial Reporting, Accounting Operations, Internal Audit, etc.
• Healthy Culture: Work in an environment with a focus on your health which allows you to thrive. The walking track, onsite gym and café are just a few of the highlights of the campus.
• Compensation & Benefits: We offer a highly competitive compensation package that includes medical benefits, 401(k), ample paid time off and a schedule that supports true work/life balance

Blue Cross & Blue Shield of Mississippi is an Equal opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

Blue Cross & Blue Shield of Mississippi is an Equal opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We offer a comprehensive benefits package that is worth approximately one-third of the salary compensation. Our benefits program is among the best in the health care field. We are looking for employees who can bring their experience, expertise and dedication to work for our customers.