Specialist IV-Post-Payment Provider Audit Clinical

GuideWell; Florida; Hybrid; USD 78,000 - 126,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Global travel health insurance

Retirement savings plan with employer

Paid time off

Holidays

Wellness program

Job summary

GuideWell seeks a senior-level audit professional to analyze high-risk provider claims post-payment for payment integrity. You will review records for DRG, CPT/HCPCS coding, and contract compliance, coordinating onsite reviews with provider executives to present findings for potential adjustments.

Role requires active clinical certification, extensive coding and claims knowledge, and ability to travel frequently. Hybrid Florida-based role with comprehensive benefits and competitive pay.

Qualifications

• 5+ years related work experience.
• Hold an active clinical certification (e.g. RN, LPN, PA).
• Proficiency with claims processing procedures and provider contracts.

Responsibilities

• Independently perform analysis of high-risk claims on a post-payment basis using clinical, coding and claims processing background.
• Audit high-risk claims for appropriate use of Florida Blue policies and industry standards.
• Review medical records to validate issues on high-risk claims.
• Determine claim-level financial impact based on member benefits and contracts.
• Ensure compliance with Federal, State, BCBS and other guidelines.
• Plan and coordinate onsite reviews with providers.
• Document issues to support claim adjustments with rationale.
• Lead onsite closing meetings with provider executives to communicate findings.
• Identify upstream process gaps driving incorrect payments.

Skills

ICD-9/10 coding

DRG coding

CPT/HCPCS coding

Medical terminology

Claims processing procedures

Provider contracts knowledge

Excel / Word proficiency

Strong communications

Travel willingness

Education

Bachelor's degree or related equivalent experience

Active clinical certification (RN/LPN/PA)

Masters degree (preferred)

Tools

Diamond

Jiva

APT

EIP

Siebel

ICN

Quest

Contract Management System

Burgess

PPS Pricer

AHA Coding Clinic

Encoder

Alineo

Job description

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.

Job duties include but are not limited to:

• 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

Job Requirements:

• 5+ years related work experience. Experience Details: Strong familiarity with ICD-9/10, DRG, CPT/HCPCS coding, or experience with and knowledge of multiple provider reimbursement and pricing methodologies (DRG, SPC, OFS, POC, Global Pricing, Per Diem etc.), or 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
• Related Bachelor's degree or additional related equivalent work experience
• Hold an active clinical certification (e.g. RN, LPN, PA)
• The ability to travel frequently
• Proficiency/experience working with some of the following Tools/Apps: Diamond, Jiva, APT, EIP, Siebel, ICN, Quest, Contract Management System, Burgess, PPS Pricer, AHA coding Clinic, Encoder, Alineo
• Working knowledge of COB/OPL, Subrogation and Workers' Comp, standard claims adjustment processes and benefit plans
• Working knowledge of personal computer and related software (e.g., Excel, Microsoft Word)
• Demonstrate flexibility in unplanned work and/or project support
• Excellent oral and written communications skills

Preferred:

• Strong analytics experience
• Consulting experience
• Masters Degree
• Professional Medical Coding Certification (CPC, CCS, etc.)within 18 months of hire

General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

This position offers a hybrid work arrangement which combines flexibility with in-office engagement. Team schedules are determined based on role requirements and business needs. Travel to and from our corporate or regional offices may be required.

What We Offer:

As a Florida Blue employee, you will be at the heart of GuideWell's vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance;
• Income protection benefits: life insurance, short- and long-term disability programs;
• Leave programs to support personal circumstances;
• Retirement Savings Plan including employer match;
• Paid time off, volunteer time off, 10 holidays and 2 well-being days;
• Additional voluntary benefits available; and
• A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Salary Range: $77,600 - $126,100

Typical Annualized Hiring Range: $77,600 - $97,000

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.