We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Residency in or relocation to Louisiana is preferred for all positions.

Grade 07

POSITION PURPOSE

Audits claims to identify incorrect provider billing practices. Conducts special focus audits to identify claims and provider reimbursement related problems, including medical coding and processing issues. Coordinates research, audit, and recommendations with other areas in order to take corrective action by providers or BCBSLA. Ensures Provider and BCBSLA compliance with member and reimbursement agreements. Responsible for overseeing of projects and developing leads for the audit staff.

NATURE AND SCOPE

• This role does not manage people

• This role reports to this job: MANAGER, PAYMENT INTEGRITY, NON-CLINICAL

• Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with:Medical Management, Customer Service, Benefits Administration, IT, and other employees as needed. Providers, subscribers, other insurance companies.

QUALIFICATIONS

Education

• Bachelor's Degree in Business or related field required

• Four years of related experience can be used in lieu of a Bachelor’s degree.

Work Experience

• 2 years of claims experience which includes at least two of the following: experience analyzing claims payments, providing technical audit direction, and verifying the accuracy of ICD-9/10 and CPT-4 coding (encoder and grouper software) required

• Six months of experience coding, paying claims or auditing claims payments and/or a BCBSLA Internship may substitute for one of the three years

• Experience working with related software including database, spreadsheet, word processing and coding validation software required

Skills and Abilities

• Proficiency: Intermediate; Basic understanding of networks, reimbursement programs, member agreements, provider coding and billing, automated claims procedures, contracts and related claims data.

• Proven analytical, organizational and interpersonal skills. Effective communication and training skills.

• Ability to independently coordinate audit priorities, handle multiple tasks concurrently and support departmental operations.

Licenses and Certifications

• Certified Professional Coder (CPC) certification preferred upon hire but must be attained within 2 years after date of hire.

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

• Coordinates and conducts special focus audits. Audit claims to identify improper billing practices, internal system problems, processing errors, and analyze payment reduction options. Develops report format and criteria.

• Performs independent audits to include data collection, research, claims analysis, reports, and payment adjustments.

• Initiates and tracks problem resolution for referrals from providers and from internal departments.

• Develops leads for audit staff and provides technical support on special projects.

• Trains and updates staff on FACETS applications and specialized audit software

• Coordinates departmental projects, and problem resolutions for software applications with IT. Also, works with IT on mainframe report development and modification.

• Performs other related duties as needed, including but not limited to, back up support for other employees.

• Accountable for complying with all laws and regulations that are associated with duties and responsibilities.

Department Specific Accountabilities and Essential Functions

• Executive Management - SUP2.0:

Additional Accountabilities and Essential Functions

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

• Perform other job-related duties as assigned, within your scope of responsibilities.

• Job duties are performed in a normal and clean office environment with normal noise levels.

• Work is predominately done while standing or sitting.

• The ability to comprehend, document, calculate, visualize, and analyze are required.

#LI_SH1

An Equal Opportunity Employer

All BCBSLA EMPLOYEES please apply through Workday Careers.

PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)

Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.

In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.

JOB CATEGORY: Insurance