Blue Cross and Blue Shield of Kansas City · 12 hours ago
Payment Compliance Specialist
Kansas City, MO
Full-time
Onsite
Entry, Mid Level
1+ years expBlue Cross and Blue Shield of Kansas City is committed to providing health, financial, and lifestyle benefits to ensure a best-in-class employee experience. The Payment Compliance Specialist will conduct clinical reviews of medical documentation for appropriate coding and billing, and represent the SIU/Payment Compliance Unit to both internal and external stakeholders.
Association
Responsibilities
Conducts pre-payment reviews of medical documentation to ensure appropriate coding, provide medical review interpretation and medical necessity
Perform ongoing FWA risk assessments, leveraging data analytics to identify trend, patterns, outliers relative to peers and clinical standards, etc
Provide written and verbal education to our provider network regarding documentation deficiencies found during prepayment reviews, e.g., applicable medical coding guidelines, Blue KC Medical Policies, as well as CMS medical policy standards
Conduct prepayment investigations of FWA in accordance with SIU policies and procedures. May work with Investigators and/or Senior Investigators on larger, more complex, investigations
Create and maintain detailed case files in accordance with SIU policies and procedures, where key investigative activities and outcomes are timely and accurately documented
Perform day-to-day activities for vendor-based claim overpayment recovery program (e.g., data file exchanges, proposing / reviewing new audit concepts, coordinating claim adjustments, invoices)
Prepare reports for FWA Work Group meetings, executive updates, Blue KC Audit Committee, BCBSA/FEP surveys, and other reports as needed
Qualification
Required
1-3 years' experience performing quality coding audits of inpatient and outpatient records to assure appropriateness and accuracy of code assignments
Thorough knowledge of health insurer operational processes (e.g., member services, provider contracting and reimbursement, claim processing, customer service, and medical policies)
Excellent written and verbal communication skills and experience dealing with a broad range of audiences (e.g., Blue KC employees and senior management, law enforcement, attorneys, providers, members, customer groups and regulators)
Coding Certification: AAPC CPC, AHIMA must be obtained within 12 months of hire date
Preferred
Associates degree in criminal justice, health care administration, accounting, business, medical or other relevant academic discipline
3 years' experience performing quality coding audits of inpatient and outpatient records to assure appropriateness and accuracy of code assignments
Thorough knowledge of Blue KC's operational processes (e.g., member services, provider contracting and reimbursement, claim processing, customer service, and medical policies)
Excellent written and verbal communication skills and experience dealing with a broad range of audiences (e.g., Blue KC employees and senior management, law enforcement, attorneys, providers, members, customer groups and regulators); ability to create and deliver effective training programs to Blue KC employees
FWA Certification: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI)
Medical License: Registered Nurse (RN), Licensed Practical Nurse (LPN)
Benefits
Comprehensive medical, dental and vision benefits
401(k) plan that both the employee and employer contribute
Annual incentive bonus plan based on company achievement of goals
Paid holidays
Paid time off
Volunteer time off
Professional development courses
Mentorship opportunities
Tuition reimbursement program
Paid parental leave
Adoption leave with adoption financial assistance
Employee discount program
Company
Blue Cross and Blue Shield of Kansas City
Blue Cross and Blue Shield of Kansas City (Blue KC) is an independent licensee of the Blue Cross Blue Shield Association and a not-for-profit health insurance provider serving more than one million members in 32 counties in greater Kansas City and northwest Missouri and Johnson and Wyandotte counties in Kansas.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Erin Stucky
President and CEO
Amber Mustard
Chief Technology Officer
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