Prepayment Review Coding Specialist

The position serves as a Prepayment Review Coding Specialist within the Fraud Investigation & Prevention Unit (“FIP”). The position will be a dedicated coding specialist reviewing medical records to identify instances of health care fraud, waste, and abuse and to facilitate accurate claim payments.  The Prepayment Review Coding Specialist will conduct pre-payment reviews of claims submitted by providers and members to determine if services rendered are billed accurately to BCBSMA.   During such reviews, the coding specialist requests medical records and other documents to substantiate the services billed.  This process allows for claims to be reviewed prior to adjudication to ensure claims are billed appropriately and prevents unsubstantiated payments from being issued to providers. This individual will collaboratively work with the senior investigators where investigative expertise is required. The position provides coding consultation and education to all internal and external customers and providers as needed. 

This role is open to candidates local to our Boston, MA or Hingham, MA office.

Your Day to Day

• Utilize comprehensive knowledge, coding resources and reference materials of CPT, HCPCS, ICD-10, and modifiers to determine appropriate coding for complex claims

• Perform complex retrospective and prepayment reviews of medical records and applicable documentation to identify potential fraud, waste, and abuse and inappropriate billing practices.

• Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies.

• Provide instructions to the claims operations department prepayment reviews to initiate claim adjustments

• Provide coding consultation and education to all internal and external customers and providers

• Follow HIPAA regulations and maintain a working knowledge of various laws, regulations and industry guidelines and legal requirements to ensure compliance with state and federal regulations

• Consult investigators and data analysts to identify fraud and abuse by utilizing coding expertise to analyze patterns in billing activities

• Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices

• Responsible for contributing to the development and implementation of pre-payment review procedures and cases

• Coordinate review processes with other departments to prevent inappropriate utilization of resources

• Form recommendations regarding process improvements to eliminate provider fraud opportunities

• Analyze, track and run financial savings reports by utilizing case management software

We’re Looking for:

• The ability to handle complex and confidential matters in a professional manner

• The ability to respond to demands and strict timelines in a fast-paced environment

• A proficient understanding of medical coding and medical record reviews

• Demonstrated analytical thinking skills

• Knowledge of claims processing and adjudication by health insurers

• Knowledge of health care delivery systems with an emphasis on medical and payment policy

• Excellent written and oral communication skills

• Knowledge of NASCO, Data Warehouse and EncoderPro is a plus

• Proficiency at intermediate level with Microsoft Office- Word, Outlook, PowerPoint, Excel and Access

What You Bring:

• CPC certification is required, CEMC is a plus

• 5+ years Claims experience is required

• Investigative experience is a plus

What You’ll Gain:
The opportunity to join the Fraud Investigation and Prevention Unit, which is a unique Unit within the Legal Department, that focuses on preventing fraud, waste, and abuse. The Unit includes a team of Senior managers, data analysts, fraud investigators, certified coders and medical providers.

High school degree or equivalent required unless otherwise noted above

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.