Pre-Payment Review Specialist, Advanced

Your Role
The SIU (Special Investigations Unit) Prepayment Review team is responsible for ongoing review of claims and claim data. The SIU Pre-Payment Review Specialist, Advanced is responsible for ongoing review of claims and claim data associated with known industry Fraud Waste and Abuse (FWA) schemes. This person will report to the SIU Pre-Payment Review Supervisor. In this role you will you will make independent determinations and articulate written instructions to send to our internal Customer Service Operations and Provider Dispute Resolution teams how to further process the claims under review. This will include on whether to approve, adjust, or deny a claim due to identified FWA elements.
Your Work
In this role, you will:

• Be considered a Subject Matter Expert (SME) with one product cross functionally
• Consistently exceed established performance metrics
• Process multiple claim types or specialties
• Given special assignments; coordinates with other departments for resolution if needed
• Have a solid understanding and knowledge of system processing with the ability to not only identify errors but to analyze and resolve them
• Assist with documentation review and supports questions as needed
• Works with Special Investigator Unit Investigators, Analysts, and Triage Intake Specialists when claims and/or data reveal patterns of potential fraud, waste, or abuse, across all commercial and government lines of business, escalating findings for further investigation, regulatory and law enforcement referral
• Responsible for securing and reviewing supporting documentation, such medical records, clinical chart notes, provider and member disputes, according to industry standards in medical billing and coding and based on in-depth knowledge of BSC’s payment and medical policies

Qualifications
Your Knowledge and Experience

• Requires minimum of 5 years of experience. May require vocational or technical education in addition to prior work experience
• Requires broad knowledge of operational systems and practices typically gained through extensive experience and/or education
• Certified Professional Coder Certificate preferred
• Knowledge of medical plans and benefits. Requires basic job knowledge of systems and procedures obtained through prior work experience or education
• Intermediate-Advanced skills creating documents/files using Excel, Outlook, Power Point, and Word
• Requires extensive experience in claims processing

Pay Range:
The pay range for this role is: $ 19.83 to $ 27.76 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
About Us
At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in , Join us!