Compliance Billing and Coding Auditor, Senior

Senior Clinical Compliance Auditor

Be part of a vision for a healthier Mississippi as a Senior Clinical Compliance Auditor.

At Blue Cross & Blue Shield of Mississippi, we're not just about providing health insurance, we are creating a strong, supportive community which encourages every Mississippian to live their healthiest life. By combining strong financial stewardship with a focus on the Health & Wellness of Mississippians, we invest in programs, partnerships, and innovations which drive quality care, lower costs, and healthier lives.

We are seeking a Senior Clinical Compliance Auditor to act as the primary clinical reviewer of analytical findings, complaints, formal referrals, and appeals related to the care or services provided by Network Hospitals, Providers, Pharmacies and other entities. This Senior Auditor reviews suspected instances of inappropriate billing of claims to Blue Cross & Blue Shield of Mississippi.

Conducts clinical reviews of medical records against guidelines, Provider contracts, Member Benefit Plan language and Medical Policy criteria. Consults with Medical Director and Legal Operations with related questions during the auditing process.

Reviews data analytical findings to identify aberrant patient care, utilization or billing practices.

Determines and recommends appropriate interventions to address and resolve potential fraud, waste and abuse issues.

Prepares written reports of audit outcome and conclusions with details of findings.

Bachelor's degree in Nursing.

Knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases, 10th Revision (ICD-10) coding with applicable certification.

Intermediate proficiency using Microsoft Office, specifically Excel.

Interpersonal skills that guide group dynamics from leading meetings and articulate clinical findings objectively, to guiding sensitive discussions, building consensus and gaining buy-in without direct authority.

Ability to author objective, legally sound, evidence-based reports, synthesizing complex clinical and legal jargon into plain language.

Ability to work at a high degree of accuracy with information that is confidential in nature.

Background in Utilization Management or Medical Review.

Well-founded understanding of healthcare regulations of reimbursement and coding.

Build foundational knowledge in finance and investment accounting.

Clear pathways to grow your career where your skills flourish, including Treasury, Financial Reporting, Accounting Operations, Internal Audit, etc.

Compensation & Benefits: We offer a highly competitive compensation package that includes medical benefits, 401(k), ample paid time off and a schedule that supports true work/life balance

Set up a Workday account and complete your application process.

Processes may include phone screen, testing, in-person interview (s), background and drug testing.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.