**Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:** **Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute** **Annual incentive bonus plan based on company achievement of goals** **Time away from work including paid holidays, paid time off and volunteer time off** **Professional development courses, mentorship opportunities, and tuition reimbursement program** **Paid parental leave and adoption leave with adoption financial assistance** **Employee discount program** **Job Description Summary:** As part of Blue KC’s Special Investigation Unit (SIU), the Payment Compliance Specialist will conduct clinical reviews of medical documentation for appropriate coding and billing. Research, review and analyze data to make payment determinations. Represent the SIU/Payment Compliance Unit to both internal and external stakeholders. Document findings and recommendations in accordance with SIU policies and procedures. **Job Description** + Conducts pre-payment reviews of medical documentation to ensure appropriate coding, provide medical review interpretation and medical necessity. + Perform ongoing FWA risk assessments, leveraging data analytics to identify trend, patterns, outliers relative to peers and clinical standards, etc. + Provide written and verbal education to our provider network regarding documentation deficiencies found during prepayment reviews, e.g., applicable medical coding guidelines, Blue KC Medical Policies, as well as CMS medical policy standards. + Conduct prepayment investigations of FWA in accordance with SIU policies and procedures. May work with Investigators and/or Senior Investigators on larger, more complex, investigations. + Create and maintain detailed case files in accordance with SIU policies and procedures, where key investigative activities and outcomes are timely and accurately documented. + Perform day-to-day activities for vendor-based claim overpayment recovery program (e.g., data file exchanges, proposing / reviewing new audit concepts, coordinating claim adjustments, invoices). + Prepare reports for FWA Work Group meetings, executive updates, Blue KC Audit Committee, BCBSA/FEP surveys, and other reports as needed. **Minimum Qualifications** + 1-3 years’ experience performing quality coding audits of inpatient and outpatient records to assure appropriateness and accuracy of code assignments + Thorough knowledge of health insurer operational processes (e.g., member services, provider contracting and reimbursement, claim processing, customer service, and medical policies) + Excellent written and verbal communication skills and experience dealing with a broad range of audiences (e.g., Blue KC employees and senior management, law enforcement, attorneys, providers, members, customer groups and regulators) + Coding Certification: AAPC CPC, AHIMA must be obtained within 12 months of hire date. **Preferred Qualifications** + Associates degree in criminal justice, health care administration, accounting, business, medical or other relevant academic discipline + 3 years’ experience performing quality coding audits of inpatient and outpatient records to assure appropriateness and accuracy of code assignments + Thorough knowledge of Blue KC’s operational processes (e.g., member services, provider contracting and reimbursement, claim processing, customer service, and medical policies) + Excellent written and verbal communication skills and experience dealing with a broad range of audiences (e.g., Blue KC employees and senior management, law enforcement, attorneys, providers, members, customer groups and regulators); ability to create and deliver effective training programs to Blue KC employees. + FWA Certification: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI) + Medical License: Registered Nurse (RN), Licensed Practical Nurse (LPN) **Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.** **At Blue Cross and Blue Shield of Kansas City (Blue KC), we have long put our members first by developing products and services to meet their needs. From our founding in 1938 to more than 80 years of experience in innovative, patient-centered healthcare coverage, Blue KC continues to keep our members at the center of everything we do. As a market leader, we continue to embrace new ideas to make healthcare more affordable and to improve the customer experience. Come join us!** **Blue Cross and Blue Shield of Kansas City will extend reasonable accommodations to qualified individuals with disabilities who are otherwise not able to fully utilize electronic and online job application systems. For assistance, please send an email to** Recruitingteam@bluekc.com . EOE/Veterans/Disability Affirmative Action Employer E-Verify Participation (https://bluekcmemberportal.azureedge.net/pdf/2024/E-Verify\_Participation\_Poster\_Eng\_Es.pdf) Equal Employment Opportunity/Nondiscrimination/Affirmative Action Policies IER Right to Work (https://www.e-verify.gov/sites/default/files/everify/posters/IER\_RightToWorkPoster%20Eng\_Es.pdf) FMLA Employee Polygraph Protection Act (https://www.dol.gov/whd/regs/compliance/posters/eppac.pdf)