Sr. Audit Specialist, Data Mining - Hingham, United States - Blue Cross Blue Shield of Massachusetts

Description

What We Need

The Senior Audit Specialist role will review paid claims for coding accuracy in accordance to claims processing guidelines, BCBSMA Medical and Payment Policies, contract interpretations and established audit protocols.

The role involves detailed claims analysis of complex issues including but not limited to; understanding the specifics of new and existing claim systems/applications, how to identify opportunities for improvements by reviewing BCBSMA Medical and Payment policies, and review appeals to support the validity of the projects performed.

We are looking for an individual who is passionate about problem solving, possess strategic critical thinking skills, has an interest in the Audit field and is focused on delivering results.

This position is eligible for our Flex persona.

Your Day to Day

• Analyze data to assess the accuracy of claims payments
• Determine root causes of claim processing problems/errors and provides recommendations for improvement in claims process for continuous quality improvement
• Be responsible for all aspects of project analysis from conceptualization, development of queries, execution, problem identification, recovery, reporting and recommendations for future mitigation.
• Integrate data from multiple internal and external resources to develop and present recommendations for recoveries to management
• Collaborate actively with management to identify meaningful and measurable aspects of key work processes and areas to target for recoveries
• Work collaboratively with business and financial leaders to develop mutually acceptable recovery work plans

*This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.

What you Bring:

• A proven problem solver who can work under their own initiative
• Excellent written and verbal communication skills
• A background that supports excellent organization, problem-solving, communication, teamwork, and interpersonal skills
• A demonstrated flexibility and willingness to change as business needs change within the organization
• Broad and in-depth knowledge of financial/data analysis and the ability to function independently and creatively.

Education and Experience:

• BA/BS or equivalent related professional experience
• Minimum of 5 years of related professional experience
• Skilled at manipulating and analyzing large data sets using Excel
• Skilled at utilizing Nasco, Cognos, SAS, SQL, Python, CXT
• Understanding of medical terminology and industry standard medical coding; ICD10, CPT, HCPC, Revenue codes
• Experience with contracting, medical and payment policy, reimbursement methodology
• CPC, CCS, CPMA certification is preferred

It is our mission at Blue Cross Blue Shield of Massachusetts to foster a culture that enables associates to do their best work while living happy and healthy lives. That's why we offer you a variety of ways to support your best physical, emotional, financial, and social well-being. For more information on our benefit offerings, visit

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Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.

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Number of Openings Available

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join our Talent Community to stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.