Senior Clinical Compliance Auditor, Healthcare Compliance (MS)

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

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