JOB SUMMARY:
Perform on-site medical record reviews and quality assurance reviews of BCBSRI claims to ensure proper reimbursement within existing BCBSRI billing policies and reimbursement principles. Oversee compliance of the AHA Official Coding Clinic guidelines as well as Contract language.

REPRESENTATIVE JOB DUTIES:
* Perform on-site billing validation audits which include auditing inpatient and outpatient records for all institutional providers, physician services and/or ancillary providers. Audits are performed in the field, and the focus is to ensure that corporate liability is in accordance with our contractual arrangements, correct coding and BCBSRI policies.

* Review, research and interpret documentation from the medical record and or billing procedure. Prepare workpapers and document audit reports. Plan and conduct exit conferences with hospital, administrative and medical staff.

* Perform BCBSRI in-house quality assurance reviews, which include review of inpatient (Per Diem, Charge based) as well as outpatient services (for example: Fixed Fee, All Inclusive Rates, Percent of Charge, Emergency Room, Observation Room, Ambulatory Surgery and Ancillary Services).

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