Specialist IV-Post-Payment Provider Audit Clinical

• 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

• 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

• 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.

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