Audit Manager

What We Need

The Audit Manager will lead the Professional and Hospital Bill Audit provider audit team of 6 individuals and serve as a subject matter expert in medical coding and billing, hospital outpatient and professional audits and operations. This role will also be an interface between internal and external stakeholders collaborating with a variety of business areas including Fraud Investigation and Prevention, Health and Medical Management, Network Management and the external provider community. The Audit Manager should be capable of contributing effectively to cross-functional payment integrity initiatives.

Key Responsibilities:

• Responsible for talent management for a team that performs outpatient and professional external provider medical record reviews to verify the accuracy of claims reimbursement, clinical significance, medical necessity, coding and billing.
• Comprehensive oversight of appeals, medical record audit pipeline, financial projections, and operational effectiveness.
• Assures compliance with BCBSMA guidelines, policies and procedures.
• Interfaces with provider leaders, resolves conflicts, and develops proactive approaches for future coding discrepancies and ensure billing compliance.
• Works closely with corporate business partners to contribute to activities that lead to cost avoidance initiatives.
• Promotes innovation solutions and pursues new opportunities for pre-pay and post-pay savings that contribute to the company's annual financial and service targets.
• Prepare appeal disposition rationale, using national coding criteria sets including clinical evidence and/or regulatory documentation.
• Discuss documentation-related and level of care decisions with providers at audit closes and scheduled meetings as required.

Requirements

• Active Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) through AHIMA or AAPC is required
• CPC-I, CCS, CDEO, and/or CPMA certification is a plus.
• 5 years' experience in management operations in a team leader role
• Analytic, problem-solving, time management, organizational and communication skills
• The ability to successfully manage multiple projects and competing priorities

#LI-Hybrid

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.