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Blue Cross Blue Shield of Massachusetts
Quincy, MA, United States
22 days ago
HCA Healthcare
Brentwood, TN, United States
24 days ago
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Portland, OR, United States
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Blue Cross Blue Shield of Massachusetts
Quincy, Massachusetts, United States
22 days ago


The Sr. Hospital Bill-Outpatient Auditor is responsible to verify the accuracy of claims reimbursement, clinical significance, medical necessity, coding, and billing in accordance with the Plans’ provider agreements and the National Healthcare Billing Audit guidelines. Often serving as one of the “faces” of the Company to provider organizations across Massachusetts, the Hospital Bill Auditor helps to improve clinical outcomes and quality of care, to reduce medical expense by conducting audits and often reviewing the results with the providers.

The individual will be a subject matter expert in regard to coding and billing. S/he will also respond to inquiries from a wide variety of internal and external stakeholders and for providing claims information, data, claim summaries, and analysis. S/he will collaborate with a variety of business units including Fraud and Abuse, Health and Medical Management (including Medical Directors), Network Management and our external Provider community. Therefore, the successful candidate must be capable of building and maintaining strong working relationships with key internal and external constituents and working effectively in a matrixed environment.

***This position is eligible for the following personas: E-Worker, Mobile and Resident***


Core duties and responsibilities include but not limited to the following:

  • Preform post pay audits on hospital bills and medical records to assure all services and charges are supported by clinical documentation.
  • Assures appropriate application of BCBSMA guidelines, policy and procedures, and claims system edits.
  • Assesses medical necessity and/or clinical significance in addition to coding compliance and identifies opportunities for savings and cost avoidance.
  • Conducts provider appeals and consults with medical director when necessary.
  • Analyzes trends and billing behaviors of the audited facility and prepares feedback with audit findings.
  • Monitors and identifies existing & emerging issues/trends and keeps relevant stakeholders informed of assessed levels of risk.
  • Identifies potential quality of care issues and potential fraud, waste, or abuse. Makes referrals for follow-up as necessary.
  • Actively participates in internal/external meetings, training activities and other cost and trend initiatives.
  • Pursues new opportunities for cost avoidance savings that contribute to the company's annual financial and service targets.
  • Meets deadlines and commitments by tightly managing deliverables, coordinating matrixed inputs and ensures all tasks are performed to bring projects to timely closure.
  • Represents department on cross functional workgroups and projects as needed.
  • Other duties as assigned


  • Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs workflows and procedures.
  • Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
  • Oral Communication - Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
  • Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.
  • Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality
  • Character - Demonstrates unquestionable integrity in every aspect of work and dealing with others; Consistently models desired behaviors and values established by the company; Respect diversity of perspective in discussions and demonstrates an inclusive style; Demonstrates concerns for job safety for self and others.
  • Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; Supports organization's goals and values; Supports affirmative action and respects diversity.
  • Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Completes tasks on time or notifies appropriate person with an alternate plan.
  • Administrative Management - Continuously manages administrative functions to ensure quality and timeliness, manages accurate and timely activity and performance reports.


  • Active certified coder (RHIA, RHIT, CCS, and/or CPC) required.
  • Must be available to travel to healthcare facilities in Massachusetts when required and/or as necessary
  • Registered nurse (LPN, BSN and related advanced degree) or other relevant clinical experience is preferred.
  • Candidate will need to maintain active certification.
  • 3-5 years’ experience reviewing, coding, and/or auditing medical records, working in a health plan or hospital environment or other hands-on work with complex medical and billing information preferred.
  • Strong organizational, project management, problem-solving and communication skills.
  • Ability to navigate and manage through difficult, complex conversations with positive outcomes.
  • Strong technical skills with ability to learn audit platforms such as STARRS, NASCO, Microsoft Office products a plus.  Familiarity with Electronic Medical Record systems. 
  • Ability to work as part of a team with a positive attitude while also able to work independently.
  • Position offers remote access (E-Working) options

Job Information

  • Job ID: 63082314
  • Location:
    Quincy, Massachusetts, United States
  • Position Title: R04763 Sr. Hospital Bill Outpatient Auditor
  • Company Name For Job: Blue Cross Blue Shield of Massachusetts
  • Org Type: Remote
  • Job Function: Auditing,
    Coder/medical coder,
    Clinical Documentation Improvement (CDI),
    Coding - Outpatient
  • Job Type: Full-Time
  • Min Education: High School

Please refer to the company's website or job descriptions to learn more about them.

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