• Washington, D.C

Blue Cross Blue Shield Association - Clinical Auditor

The Clinical Auditor is a clinically experienced professional who has a strong background in patient care, patient delivery systems and/or familiarity with FEP guidelines. The Clinical Auditor will conduct clinical audits of Plans within the FEP Program. The position is responsible for reviewing policies and procedures, internal controls, and claims / medical records to determine compliance with FEP rules and regulations.


Responsibilities include but are not limited to: 

•Evaluates the level of compliance with applicable federal regulations, contractual requirements, and Association policies and procedures at FEP Director’s Office, Plans, the Vendors and the FEP Operations Center. Maintains FEP compliance plan as part of these activities. Recommends, develops, and delivers training, as necessary, to address potential risks at FEPDO and various Plans. Track and monitor corrective action plans from various audits performed by FEPDO. Acts as the point of contact and “manager of the engagement” within FEPDO for all issues related to assign Plans, OPM and vendor audits relating to case management and utilization management. 

•Lead project teams in completing various audit activities in the Program Assurance Plan, including direct experience in auditing medical chart review for FEP claims, experience with medical necessity determinations applying clinical judgment, case management and utilizing medical necessity criteria.

•Acts as a subject matter expert with FEP Clinical policies and procedures to Plans and/or vendor officials/management regarding the audit process; instructs audit flow facilitation; analyzes and assesses audit trends, best practices and risk; and, develops an effective overall audit strategy. Determines the necessity for Plan and/or vendor visits based on an evaluation of the issues and progress of the audit. Provides leadership, guidance, and oversight, as required, to other consultants during the audit process.

•Participate in Plans Operational Control Performance Reviews (develop, initiate, and complete the audit program or review staff work papers for completed areas of the Program).

Required Basic Qualifications:

•Must be either a registered nurse, licensed practical nurse, medical coder or clinical auditor, clinical documentation, medical necessity, and/or utilization review experience

•Excellent knowledge of DRG, ICD-9/10, CPT and HCPCS codes

•Experience with medical necessity determinations applying clinical judgment and utilizing medical necessity criteria

•Working knowledge of provider billing guidelines, reimbursement policies and related industry-based standards

•Health care industry experience with progressive responsibility in medical management with an exposure to Plan operations and/or federal government experience

•Familiarity with Health Care Coverage Determinations, medical Policy and regulations

Preferred Basic Qualifcations:

•Familiarity with FEP Coverage Determinations,

medical Policy and regulations

•Direct experience in medical chart review

•Professional and facility based medical coding

•Medical Policy/Utilization Review

•Audit/Special Investigation