Provider Auditor – DRG Validation

Blue Cross Blue Shield of Massachusetts
July 2, 2019
Quincy, MA
Job Type


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The Provider Auditor for post-pay review 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. Serving as one of the “faces” of the Company to provider organizations across Massachusetts, the Provider Auditor strives to improve correct claims payments in order to contribute to the reduction of the medical expense. The individual will be a subject matter expert in regards to coding and billing. S/he will also respond to inquiries from a wide variety of internal and external stakeholders. 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.


  • Conduct Diagnosis Related Grouper Validation (DRG) audits to verify the accuracy of claims reimbursement by applying National Healthcare Billing Audit standards, Coding Clinic guidelines published by the American Hospital Association, and the Plans’ agreements including published policies.
  • Select claims samples for medical record reviews in accordance with pre-selection criteria, billing trends, and supporting documentation.
  • Monitor existing/emerging trends and keep relevant stakeholders informed of risk areas and concerns that may require additional attention.
  • Act as a subject matter expert with internal and external stakeholders in reference to coding, billing practices, and accuracy of assigned ICD-10codes.
  • Educate on post audit findings and close audits timely using audit program databases that incorporate 3M software.
  • Identify the potential quality of care issues and service or treatment delays. Make referrals for follow-up as necessary.
  • Identify possible fraud and abuse, document billing errors, and benefit cost management and savings opportunities.
  • Actively participate in internal/external meetings, training activities and other cost and trend initiatives.
  • Identify and pursue new opportunities for cost avoidance savings that contribute to the company's annual financial and service targets.
  • Meet deadlines and commitments by tightly managing deliverables, coordinating matrixed inputs and ensuring all tasks are performed to bring projects to timely closure.
  • Represent the department on cross-functional workgroups and projects as needed.
  • Conduct audits remotely as well as onsite for certain hospitals.
  • Occasional in-state travel between provider organizations across Massachusetts required.


  • Active Certified coder (RHIA, RHIT, or CCS ) required candidate would need to maintain active certification.
  • In-depth knowledge of and ability to interpret APR-DRG, HCPCS, CPT, ICD10-CM diagnosis and procedure codes and Plan benefit designs required.
  • Clinical Documentation Improvement (CDI/CDEO) certification a plus.
  • Ability to travel for onsite audits on an as needed basis required.
  • 3-5 years’ experience reviewing 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 computer skills: – proficient in MS Word, Excel, PowerPoint and Outlook, familiarity with Electronic Medical Record systems.
  • Ability to work as part of a team with a positive attitude while also able to work independently.
  • E-working opportunities are available; however, you must reside in Massachusetts.

Company Description

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 80 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity.

ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Services at the number on your ID Card (TTY: 711).

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711).

ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

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