Quality Medical Auditor

Why should you join the BlueCross BlueShield of South Carolina family of companies? We are the largest insurance company in South Carolina and a leading administrator of government contracts. With roots in the community for over seven decades, we operate one of the Southeast’s most sophisticated data processing centers and a diverse family of subsidiary companies. We deliver outstanding service and are committed to building a team that shares this dedication.

About the Role

Performs validation reviews of Diagnosis Related Groups (DRG), Ambulatory Procedure Codes (APC), and Never Events (serious, preventable medical errors) for all lines of business. Coordinates rate adjustments with claims areas, provides monthly and quarterly trend reports, and serves as a resource for resolving coding issues. Manages HIPAA and legal records requests for Healthcare Services and the Legal Department.

Responsibilities

• Determines methodology to identify cases for validation review.
• Conducts validation reviews and coordinates rate adjustments with appropriate claims areas.
• Creates monthly and quarterly reports on records review, outcomes, trends, and savings impacting medical costs and contracting rates.
• Manages records retrieval, release, HIPAA compliance, and document management.
• Serves as an expert resource on methodology and procedures for medical records and coding issues.

Requirements

• Associate's degree in a job-related field or graduate of an accredited School of Nursing.
• 3 years of medical record management experience, including coding and validation review.
• Extensive knowledge of medical records, coding, contract evaluations, claims processing, and adjudication practices.

Qualifications

• Registered Records Administrator or Technician, or
• Active, unrestricted RN licensure in the U.S. and state of hire, or active compact multistate unrestricted RN license (Nurse Licensure Compact), or
• Certified Coding Specialist.

Skills

• Excellent verbal and written communication.
• Strong organizational, customer service, and analytical/critical thinking skills.
• Good judgment and ability to handle confidential or sensitive information with discretion.

Location

This role is based at 2401 Faraway Drive, Columbia, SC 29229, with potential for remote work.

Benefits

• Subsidized health plans, dental, and vision coverage.
• 401k retirement savings plan with company match.
• Life insurance.
• Paid Time Off (PTO).
• On-site cafeterias and fitness centers in major locations.
• Education assistance.
• Service recognition programs.
• National discounts (movies, theaters, zoos, theme parks, and more).