Coding Quality Analyst and Compliance Auditor

Pay Range:

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At BCBSRI our greatest resource is our people.

We come from varying backgrounds different cultures and unique experiences. We are hard-working caring and creative individuals who collaborate support one another and grow together. Passion empathy and understanding are at the forefront of everything we donot just for our members but for our employees as well.

We recognize that to do your best work you have to be your best self.
Its why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health dental and vision insurance as well as programs that support your mental health and well-being. We pay competitively offer bonuses and investment plans and are committed to growing and developing our employees.

Our culture is one of belonging.
We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where youre at in the organization youre an integral part of our team and your input thoughts and ideas are valued.

Join others who value a workplace for all.
We appreciate and celebrate everything that makes us unique from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders.

Were dedicated to serving Rhode Islanders.
Our focus extends beyond providing access to high-quality affordable and equitable care. To further improve the health and well-being of our fellow Rhode Islanders we regularly roll up our sleeves and get to work (literally) in communities all across the statebuilding homes working in food pantries revitalizing community centers and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can our associates receive additional paid time to volunteer.

Why this job matters:

Perform second pass coding audits of medical record review to assure appropriateness and accurate code assignments in accordance with Center of Medicare and Medicaid (CMS) guidelines. Perform audits complete reporting on a regular basis and ensure compliance with applicable coding guidelines rules and regulations. Identify and provide training for Coders and Medical Records staff.

What youll do:

• Coordinate schedule and perform audits of medical record coding according to ICD-9 ICD-10 CPT HCPCS and CMS guidelines.

• Serve as a coding resource and provide coding expertise and guidance to the entire team.

• Analyze medical documents and evaluate the quality of medical record coding to identify incomplete or inconsistent documentation.

• Document coding review findings maintain thorough and objective documentation findings.

• Calculate and distribute coding accuracy and coding completeness scores for medical record review teams.

• Identify and submit any newly supported add codes. Identify analyze and delete any unsupported diagnosis codes.

• Responsible for maintaining up to date knowledge of coding guidelines as they relate to professional services and improving coding guidelines.

• Develop and coordinate educational and training programs regarding elements of coding such as appropriate documentation accurate coding coding trends found during chart reviews third party audit findings and annual coding updates.

• Develop implement and maintain a detailed and thorough Risk Adjustment coding policy education and training for both internal and external coding teams.

• Coding Audit oversight participate and perform duties assigned as assigned Corporate Compliance responsibilities for complying with BCBSRI Compliance Program

• Commercial coordinate with the commercial coding manager to audit and provide actionable feedback on commercial RADV audit results.

• Research and interpret correct coding guidelines and monitor CMS coding and reimbursement policies.

• Prepare written reports of the audit findings and when necessary implement corrective action plans and/or educational programs.

• Coordinate quality improvement program for Medical Records and Coding functions.

• Vendor management for In Home Health Assessments

• Act as a coding subject matter expert for CMS audits. Assist analyst with creation and scrubbing of annual chart chase lists (Medicare and Commercial).

• Maintain coding certification and attend in-service training as required.

What you need to succeed:

• Bachelors degree in nursing Health Administration Business or related field or an equivalent combination of education and experience

• Medical Coding Certificate; RHIT or CPC CRC or CPMA by AAPC or AHIMA license; meet state licensure requirements.

• Prior Experience with Risk Adjustment Coding and Auditing

• Strong professional coding oversight and mentorship skills

• Excellent communication and presentations skills; ease with public speaking

• Three to five years experience in medical coding

• Three to five years experience in medical claims review or claims processing

• Experience in quantitative or statistical analysis (preferably in health care) and proven analytic experience using Microsoft Excel database query capabilities and ability to evaluate data at various levels of detail.

• Thorough knowledge of medical terminology and ICD-10-CM/ICD-9-CM coding guidelines.

• Strong organizational skills and ability to work autonomously or as an active member of a team.

• Strong computer skills in data entry coding and knowledge of Electronic Medical Record software; Microsoft Office Suite

• Understanding of medical terminology

• Accurate and precise attention to detail

• Ability to multitask prioritize and manage time efficiently

• Excellent verbal and written communication skills

• Good interpersonal skills

• Self-Starter with the ability to learn quickly.

• Knowledge of regulatory and accrediting standards including but not limited to NCQA URAC DOH DHS CMS

• Advanced analytical skills with the ability to interpret and synthesize complex data sets

• Negotiation skills

• Decision-making skills

• Strong problem-solving skills

• Ability to effectively navigate ambiguous situations with limited direction

• Ability to successfully prioritize multiple tasks.

• Ability to handle multiple priorities/projects with frequent interruptions.

Location:
BCBSRI is headquartered in downtown Providence conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states pending approval from the Human Resources Department: Arizona Connecticut Florida Georgia Louisiana Massachusetts North Carolina Oklahoma Rhode Island South Carolina Texas Virginia
  

Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do and it strengthens our ability to meet the challenges of todays healthcare industry. BCBSRI is an equal opportunity employer.

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