Senior Clinical Compliance Auditor

Healthy careers start here at Blue Cross & Blue Shield of Mississippi. We encourage professional growth in a challenging and fast-paced atmosphere. Our "be healthy" culture promotes health and wellness at all levels of the company, providing employees with the time, tools, and resources to commit to a healthy lifestyle.

About the role

The Senior Clinical Compliance Auditor serves as the primary clinical reviewer of data analysis findings, referrals, appeals, and complaints related to Network Hospitals, Providers, Pharmacies, and other entities or programs suspected of inappropriate billing of claims. The incumbent is responsible for selecting, obtaining, coordinating, monitoring, and reviewing medical records and other relevant information for clinical and coding assessment and validation of related billing of services provided to Blue Cross Blue Shield customers.

The Senior Clinical Compliance Auditor collaborates with data analysts, compliance auditors, and the Medical Director to identify aberrant trends in patient care, utilization, and billing practices. The incumbent works with a multidisciplinary team to determine appropriate interventions to address and resolve identified issues and prepares clear, detailed findings, reports, and recommendations for corrective action after thorough clinical analysis.

Requirements

• Bachelor’s degree in Nursing is required
• Registered Nurse with an unrestricted license in the state of Mississippi is required
• At least three years of healthcare clinical experience is required
• Background in Utilization Management or Medical Review is preferred
• Strong knowledge of healthcare regulations related to reimbursement and coding is preferred
• Knowledge of CPT, HCPCS, ICD-10 coding with applicable certifications is required
• Intermediate knowledge of Microsoft Office, including experience in Excel, is required
• Excellent oral and written communication skills with the ability to communicate a clear understanding of review findings
• Ability to work with a high degree of accuracy and attention to detail
• Ability to handle information of a confidential nature
• Excellent organizational skills, including the ability to prioritize multiple tasks and perform them accurately and simultaneously
• Strong interpersonal skills with the ability to build relationships to encourage trust and open communication

Benefits

We offer a comprehensive benefits package worth approximately one-third of the salary compensation. Our benefits program is among the best in the healthcare field.