Summary

Prepares for and performs institutional audits to assess appropriate provider billing and to identify any aberrant billings that may have an impact on reimbursement. Responsible for reviewing all aspects of claim processing to include fraudulent billing practices and to respond to providers on review/audit findings. Responsible for documenting cost savings related to reviews/audits. Identifies changes with hospital.

Position Purpose

Prepares for and performs institutional audits to assess appropriate provider billing and to identify any aberrant billings that may have an impact on reimbursement. Responsible for reviewing all aspects of claim processing to include fraudulent billing practices and to respond to providers on review/audit findings. Responsible for documenting cost savings related to reviews/audits. Identifies changes with hospital.

Location

This position is a full-time role, between the hours of 7:30am and 5pm. You will work an 8-hour shift during that time. This is located at 2401 Faraway Drive Columbia, SC 29223. There is the potential for hybrid work after the training time period.

Sponsorship

This position is not eligible for sponsorship now or in the future.

What You'll Do

• Conducts institutional reviews and/or audits to assess appropriate provider billing and to identify any aberrant billings that have an impact on reimbursement. Responsible for timely completion of reviews/audits and responses to inquiries. Ensures appropriateness of what has been billed and should be allowed by reviewing hospital itemized bills and hospital medical record to determine services/charges that are and are not covered and/or allowed to be billed separately. Researches the claim system to identify other claims related to the one being reviewed/audited. Responsible for timely review of high dollar claims to minimize the time between receipt of the claim and completion of the high dollar review so the claim can be paid. Some day and overnight travel to hospital locations throughout the state of South Carolina may be needed in order to perform and complete onsite audits.
• Analyzes audit findings and completes letters and reports providing the discrepancies between the medical records and the itemized bill to the provider. Responsible for notifying and providing the claim operation departments with high dollar review findings so the claim can be processed for payment. Completes and maintains audit files and internal tracking tools for each audit. Responsible for ensuring that overpayments to the provider have been recovered through claim reviews/processing and use of internal refund tracking systems. Responds to provider inquiries related to audit findings.
• Requests and analyzes reports on institutional providers to identify claims appropriate to audit after payment of the claim. Follows departmental procedures and guidelines to ensure validity of claims selected to audit. Coordinates with providers to determine an agreed upon date that the onsite audit evaluation can be performed, ensuring timely scheduling of the audit.
• Assists with and provides feedback on department policies/procedures throughout the audit/review processes. Notifies management of inconsistencies and/or changes in billing practices to rule out possible fraud and abuse. Makes recommendations to improve department productivity, cost effectiveness, and timeliness.
• Participates in department activities: committees, staff meetings, educational opportunities, etc.

To Qualify For This Position, You'll Need The Following

• Required Education: Associate's in a job related field
• Degree Equivalency: RN licensure or LPN licensure with additional one year of clinical nursing experience (the additional experience cannot be included in the required work experience).
• Required Work Experience: 3 years of clinical nursing and/or medical audit/investigations experience to include 2 years of medical/surgical bedside experience.
• Required Skills and Abilities: Knowledge of anatomy and physiology, disease processes, medical terminology, and patient care practices in order to verify accuracy of medical records. Ability to interpret medical records and itemized bills. Familiar with hospital billing knowledge and knowledge of revenue, CPT, HCPCS, medical coding, etc. Ability to communicate verbally and in writing to all levels of the organization and externally. Excellent analytical or critical thinking and problem-solving capabilities with attention to detail. Ability to make sound decisions. Ability to successfully complete multiple tasks simultaneously. Ability to work with minimal supervision in a fast-paced environment. Ability to make appropriate decisions on claims reviewed/audited in a timely and accurate manner. Good time management and organizational skills. Ability to handle confidential or sensitive information with discretion. Detail oriented.
• Required Software and Tools: Microsoft Office.
• Required Licenses and Certificates: Active, unrestricted RN or LPN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN or LPN license as defined by the Nurse Licensure Compact (NLC).

We Prefer That You Have The Following

• Preferred Skills and Abilities: Knowledge of hospital and physician audit principles, procedures, and reimbursement. Knowledge of group and/or hospital contracts or the ability to acquire. Good team building and leadership skills. Knowledge of patient care practices, anatomy, and disease processes to verify accuracy of medical records. Knowledge of hospital and physician audit procedures and requirements.
• Preferred Software and Tools: Working knowledge of Microsoft Office, especially Word, Excel and Access; working knowledge of Adobe (or the ability to acquire). Previous experience using, or the ability to learn, the BCBSSC system to access necessary information.