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Blue Cross Blue Shield of Massachusetts Pre-payment Review Coding Specialist l Certified Professional Coder l Healthcare in Boston, Massachusetts

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The position serves as a Pre-payment Review Coding Specialist within the Fraud Investigation & Prevention Unit (“FIP”). The position will be a dedicated coding specialist reviewing medical records to identify instances of health care fraud, waste, and abuse and to facilitate accurate claim payments. The coding specialist will conduct pre-payment reviews of claims submitted by providers and members to determine if services rendered are billed accurately to BCBSMA. During such reviews, the coding specialist requests medical records and other documents to substantiate the services billed. This process allows for claims to be reviewed prior to adjudication to ensure claims are billed appropriately and prevents unsubstantiated payments from being issued to providers. This individual will collaboratively work with the senior investigators where investigative expertise is required. The position provides coding consultation and education to all internal and external customers.

Key Accountabilities:

  • Utilize comprehensive knowledge of CPT, HCPCS, ICD-10, and modifiers to determine appropriate coding for complex claims

  • Perform complex retrospective and prepayment reviews of medical records and applicable documentation to identify potential fraud, waste, and abuse and inappropriate billing practices. Responsible for appeal reviews.

  • Provide instructions to the claims operations department for prepayment reviews

  • Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies

  • Prepare summary of findings and recommend next steps for providers

  • Provide coding consultation and education to all internal and external customers

  • Follow HIPAA regulations and maintain a working knowledge of various laws, regulations and industry guidelines and legal requirements to ensure compliance with state and federal regulations

  • Utilize coding resources along with any other applicable reference material available to ensure accuracy in coding for all assigned services.

  • Consult investigators and analyst to identify fraud and abuse by utilizing coding expertise to analyze patterns in billing activities

  • Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices

  • Responsible for contributing to the development and implementation of pre-payment review ideas

  • Coordinate review processes with other departments to prevent inappropriate utilization of resources

  • Form recommendations regarding process improvements to eliminate provider fraud opportunities


  • Possess ability to handle complex and confidential matters in a professional, tactful manner

  • Proficient understanding of health insurance coding

  • Demonstrates analytical thinking skills

  • Knowledge of claims processing and adjudication

  • Knowledge of health care plan benefits design for all products

  • Knowledge of health care delivery systems with an emphasis on medical policy

  • Possesses excellent written and oral communication skills

  • Ability to use computer software to analyze data; specific skills with the STARS system and EncoderPro a plus

  • Proficiency at intermediate level with Microsoft Office- Word, Outlook, PowerPoint, Excel and Access

  • Provide education as needed to both internal and external customers

Education/Relevant Experience:

  • CPC certification required, 5 plus years’ experience; CEMC a plus

  • Claims experience a plus

  • Investigative experience a plus

LocationBostonTime TypeFull time

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 75 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.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing 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 Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.