Job Summary

This position is intended to analyze claim over and under payments in support of the business unit’s objective to ensure all claims are paid accurately prior to payment and to help control medical cost spend. This role requires clinical certifications and coding certifications to independently perform reviews of high risk and/or high dollar claims from a clinical, medical coding and provider billing perspective to ensure claims payment integrity. This may include reviews of corresponding medical records to validate billing appropriateness. In addition, the role is responsible for ensuring claims are paid according to the provider and member contracts as well as ensuring that standard claims processing guidelines and billing procedures for each type of service and type of provider were followed. In this role, the RN will work closely with the Medical director and will be responsible for interacting directly and communicating with the Provider Audit RNs.

Essential Functions

• The essential functions listed represent the major duties of this role, additional duties may be assigned.
• Independently perform analysis of high risk and/or high dollar claims on a pre-payment basis utilizing clinical, coding and claims processing background to ensure claims are neither over nor underpaid. (20%)
• Leverage clinical and coding background to asses high risk claims for inappropriate application of associated Florida Blue policies and industry standard billing and care practices that may impact claims payment (e.g. MCG, LCD, Authorizations, Covered Benefits, Appropriateness of Service Setting) (20%)

Specifically:

• Request and review pertinent medical records to validate/invalidate potential issues identified on high risk claims
• Determine claim level financial impact based on unique member benefits and provider contract terms and rates.
• Ensure claims processing compliance with overarching administrative regulations (Federal, State of Florida, BCBS Association etc.).
• Perform claims level analysis of appropriate provider coding and billing practices and/or guidelines
• Coordinate and communicate directly with Provider Audit RNs / Team (20%)
• Thoroughly document identified issues to support claim adjustments (including supporting medical record, clinical or coding rationale). (10%)
• Participate in special projects, as needed, to support changes in the supporting processes or policies that will impact the pre-payment, claims or care processes. (5%)
• Coordinate and liaise with upstream and downstream processes as well as senior leaders to ensure the necessary SME participation on claim reviews and that outcomes are considered appropriately (10%)
• Identify and document upstream process gaps driving incorrect payment for remediation and prevention (10%)

Minimum Job Requirements

• Active Florida RN License
• Professional Medical Coding Certifications (CCS) with Inpatient Coding and DRG experience
• 5+ years related work experience where the skills below are obtained:
• Strong familiarity with ICD-10-CM and ICD-1—PCS, DRG, CPT/HCPCS coding,
• Experience with and knowledge of multiple provider reimbursement and pricing methodologies (DRG, SPC, OFS, POC, Global Pricing, Per Diem etc.),
• Demonstrated proficient working knowledge of at least three of the following: medical terminology, claim audit procedures, provider contracts, claims processing procedures and guidelines, provider authorizations, provider billing, medical coding, concurrent review.
• Proficiency/experience working with some of the following Tools/Apps:
• Diamond
• APT
• EIP
• Siebel
• ICN
• Quest
• Contract Management System
• Burgess
• PPS Pricer
• AHA coding Clinic
• Encoder
• Working knowledge of COB/OPL, Subrogation and Workers' Comp, standard claims adjustment processes and benefit plans.
• Demonstrate flexibility in unplanned work and/or project support.
• Excellent oral and written communications skills.
• Strong analytics experience
• General Physical Demands
• Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

Additional Preferred Qualifications

• CCDIS and AHIMA Approved trainer for ICD 10 CM / PCS
• Masters Degree in a related field

Required Education:

• Related Bachelor’s degree or additional related equivalent work experience

Required Licenses and Certifications:

• At a minimum: RN, CCS