Full-Time
Quality Assurance Coder/Auditor
Updated on 9/12/2026
Blue Cross Blue Shield of Arizona
1,001-5,000 employees
Health insurance products and services
No salary listed
Phoenix, AZ, USA
Hybrid
Must reside and work within Arizona; hybrid individual contributors are required on-site at least once per week.
 Medical, Clinical & Veterinary (1) |
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- Five years of professional coding experience, including at least three years of HCC coding experience and two years of HCC auditing experience.
- Advanced knowledge of coding guidelines.
- A High School Diploma or GED.
- A Certified Coding Specialist – Physician Based (CCS-P), Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or Certified Outpatient Coding (COC) credential.
- A comprehensive understanding of HCC coding rules, regulations, methodology, and the role of hierarchies.
- Knowledge of the CMS crosswalk of ICD diagnosis codes to Hierarchical Condition Category (HCC) codes and the impact of diagnosis coding on risk adjustment payment models.
- Knowledge of anatomy, pathophysiology, and medical terminology sufficient to correctly code diagnoses according to CMS and ICD-10 coding guidelines.
- Knowledge of Chapter 7 of the Medicare Managed Care Manual concerning risk adjustment.
- Proficiency in a Microsoft Windows environment, including Microsoft Word, Excel, and PowerPoint, and the ability to learn organizational systems and software applications.
- Strong writing skills.
- Knowledge of primary care provider office practices, electronic and manual medical record systems, and billing processes.
- Ability to develop training materials and conduct educational training to close healthcare gaps, improve medical record documentation, and ensure complete and accurate coding.
- Ability to identify and effectively communicate medical record documentation or coding deficiencies to providers and their staff.
- Review medical records and supporting documentation, determine their completeness and accuracy, identify barriers to correct coding, and recommend coding best practices and improvements.
- Determine valid encounters, including face-to-face encounters, legibility, and valid signatures, according to Medicare Managed Care requirements.
- Perform quality assurance audits on vendor and provider group supplemental data submissions and provide corrective action recommendations when accuracy scores fall below 95%.
- Track quality assurance audits and send monthly updates to vendors and the management team, including findings and recommendations regarding healthcare gaps, medical record documentation, coding, and additional educational training.
- Develop a provider and coder education program supporting risk mitigation analysis, write education tips for publications, and prepare materials for presentation during Zoom calls.
- Correct encounter rejections within the vendor platform.
- Maintain current knowledge of the Medicare Managed Care Manual, Chapter 7, risk adjustment, and Medicare outpatient billing systems and processes.
- Maintain coding certification and stay current with changes in risk adjustment methodologies.
- Work a full-time schedule of at least 40 hours per week, plus additional hours as needed to meet business requirements.
- Perform other assigned duties.
- Five years of Medicare Advantage health plan experience.
- Five years of experience with HEDIS measures or the CMS Star Program.
- Clinical training as a Medical Assistant, Registered Nurse, Licensed Practical Nurse, or Certified Nursing Assistant.
- Registered Health Information Technologist (RHIT) or Registered Health Information Administrator (RHIA) credential.
- Certified Documentation Expert Outpatient (CDEO) or Certified Professional Medical Auditor (CPMA) certification.
- Strong understanding of the Risk Adjustment Validation Audit (RADV) process for risk adjustment models.
- Knowledge of pharmacology.
Blue Cross Blue Shield of Arizona provides health insurance products and services to more than 1 million Arizonans, offering plans for individuals, families, and businesses as well as Medicare supplement plans for seniors. It operates as an independent not-for-profit licensee of the Blue Cross Blue Shield Association with a network-based model: members receive care by choosing providers within a negotiated network, while the insurer handles underwriting, benefits administration, claims processing, and care services. The company differentiates itself through its local Arizona footprint, community involvement, and not-for-profit status, plus a broad local presence across Phoenix and other cities. Its goal is to improve the quality of life for Arizonans by delivering affordable health coverage and tools to help people make better health decisions, supported by community volunteering and charitable contributions.
Company Size
1,001-5,000
Company Stage
N/A
Total Funding
N/A
Headquarters
Phoenix, Arizona
Founded
1939
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Simplify's Take
What believers are saying
- AZ Blue Health Choice enrolled over 2,100 members in Nest Health by July 2026.
- March 2025 scholarships supported up to 400 Maricopa Community Colleges students.
- April 2026 Canyon View health fair deepened AZ Blue workforce and community ties.
What critics are saying
- HonorHealth exits AZ Blue Best Life HMO network January 1, 2027.
- Dignity Health kept most BCBSAZ members out-of-network after 2024 contract failure.
- A 2026 antitrust settlement pressure still shadows the Blue Cross brand.
What makes Blue Cross Blue Shield of Arizona unique
- AZ Blue remained Arizona-based, independent, and not-for-profit through 2026.
- CMS gave AZ Blue’s 2026 Medicare Advantage plans a 4.5-star rating.
- AZ Blue invested over $6 million in 2025 community health programs.
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Benefits
Health Insurance
Hybrid Work Options
Remote Work Options
Flexible Work Hours
Company News
AZ Blue surprises school nurse with supplies at Yoga on the Field event. Blue Cross Blue Shield of Arizona recognized a local school nurse for her dedication to students and families during the annual Yoga on the Field event at Chase Field, according to an Aug. 25 announcement. The event, held in partnership with the Arizona Diamondbacks, gathered hundreds of Arizonans to focus on physical and mental well-being before a D-backs game against the Cincinnati Reds. As part of the event, AZ Blue surprised a school nurse from the Alhambra Elementary School District by providing classroom supplies and making a donation for a new laptop. These resources are intended to support students throughout the school year. Attendees also contributed by donating notebooks, pencils, crayons, glue sticks, and other classroom essentials. "School nurses play a critical role in supporting students' health, well-being and ability to succeed in the classroom," said Paul Penzone, Chief Community Relations Officer at AZ Blue. "We are proud to recognize one of these everyday heroes and help provide resources that will benefit students and families throughout the school year." The surprise is part of AZ Blue's ongoing efforts to strengthen Arizona communities by supporting those who help children learn and grow. The organization says combining wellness activities with community engagement highlights how collective action can positively impact local schools. Yoga on the Field is among several initiatives supported by AZ Blue and the Arizona Diamondbacks aimed at promoting healthier communities across Arizona. The Scottsdale Area Chamber of Commerce supports community growth through economic development initiatives, business advocacy efforts - including partnerships with entities like Arizona State University - and offers education programs designed to foster prosperity for businesses throughout Scottsdale, according to the official website.
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New grant expands postpartum and mental health support for Arizona Moms. BY Frontdoors Media For many Arizona families, the support needed after bringing home a new baby can be difficult to access. As postpartum care and maternal mental health needs continue to grow, one Arizona nonprofit is working to close those gaps by expanding community-based support for new mothers. 4th Trimester Arizona is growing its It Takes a Village initiative with the help of a $100,000 Thiru Family Trust Momentum Maker Grant from the Blue Cross Blue Shield of Arizona Foundation, creating more pathways for doulas to serve families during pregnancy, birth and postpartum recovery. The funding is helping train, certify and contract more community-based doulas across Arizona, strengthening a statewide support system and bringing care directly into communities where it is needed most. The initiative also focuses on helping doulas become providers for families covered through AHCCCS, Arizona's Medicaid program. "This funding has helped move the It Takes a Village project from concept to implementation by building the support system community-based doulas need to serve families covered through AHCCCS," said Dr. Jennie Bever, CEO of 4th Trimester Arizona. "Moms need more support than the current system provides. By helping doulas navigate the reimbursement pathway, we're expanding access to trusted, relationship-based care." Since receiving the grant last year, the program has already made measurable progress. To date, 13 doulas have completed state certification, nine have moved through Medicaid approval steps, nine have begun working through health plan agreements and two have become approved providers with at least one health plan. The work comes at a critical time. In Arizona, one in five women experiences maternal mental health symptoms, and maternal mental health conditions remain the most common complication of pregnancy and childbirth. For many families, doulas serve as trusted guides throughout pregnancy and beyond, offering emotional support, education and advocacy while helping parents recognize warning signs and navigate care systems. "What makes community-based doulas especially powerful is trust," Bever said. "Families are often more likely to share concerns with someone who understands their lived experience, culture, language, and community context." For doulas themselves, the initiative is also creating a more sustainable path for them to continue serving. "This amazing program has provided a pathway for me to continue serving families as a doula in a sustainable way," said Brionna Giles, certified doula and founder of Your Birth Story Birth Services. "I can't wait to pay this kindness forward in the work I do." Through its foundation, community giving initiatives, and Medicaid team, AZ Blue continues to invest in maternal health resources across Arizona, helping more mothers access the care, support, and connection they need during one of life's most transformative seasons. For more behind this Frontdoor, visit 4thtrimesteraz.org. Frontdoors Media Frontdoors Media celebrates the people and groups who give generously and work to build the future of its community. It's the premier source of information - and inspiration - for those who strive to make the Valley of the Sun a better place to live.
Summus strengthens Executive team with appointment of Mike Tilton as Chief Commercial Officer. New York, May 30: Summus, the only physician-led, multi-specialty platform delivering longitudinal support to the highest-cost, most complex members across their entire care journey, today announced the appointment of Michael P. Tilton as Chief Commercial Officer. Tilton joins as employers and health plans face mounting pressure to improve outcomes and contain costs for their most complex members. In this role, Mike will lead go-to-market strategy across all channels to further scale Summus' innovative clinically-led approach with health plans and employers to deliver better health care and support more complex and rising risk members. Veteran Healthcare Executive Mike Tilton Joins as Summus Scales Its Physician-Led Multi-Specialty Platform "We're thrilled to welcome Mike to the Summus team at a significant moment in healthcare and for our company," said Julian Flannery, Founder and CEO of Summus. "With annual healthcare costs rising 9% and specialty care remaining highly fragmented, employers are focused on consolidating point solutions and supporting their most complex and rising-risk members to bend the cost curve. Mike's deep experience in healthcare and across the largest health plans positions him to meaningfully impact existing and future partnerships across health plans, benefits consultants, and self-insured employers at this important growth inflection point for Summus. His leadership and strategic lens will be instrumental as we scale our platform and continue to advance our vision of one platform, every health journey." Tilton joins Summus with more than two decades of senior leadership experience across Fortune 500 healthcare organizations and high-growth health tech companies. Most recently, he served as Senior Vice President of Specialty and Retiree Solutions at Humana, where he managed a portfolio of businesses representing over $12.7 billion in annual revenue, including the Ancillary Group, Individual and Medicare Supplemental Benefits, Wellness, Medicare Supplement, and Group Medicare businesses. Prior to Humana, Tilton served as General Manager of the Commercial Segment for Blue Cross Blue Shield of Arizona, where he led a statewide team across Product, Operations, Group Sales, Finance, and Underwriting, delivering over $2 billion in revenue while significantly improving administrative services only (ASO) profitability. He also served as a Board Member and Advisor to Consortium Health Plans, helping integrate best practices and enable National Account strategies across the BCBS system. Earlier in his career, Tilton held senior positions at UnitedHealth Group, Cigna, GlaxoSmithKline, and U.S. Healthcare, with responsibilities spanning PBM contracting, payer access, provider contracting, underwriting, and go-to-market strategy. He has also worked with healthtech companies on commercial strategy and as an Operating Partner for venture-focused investment funds. "Summus has built something genuinely different in healthcare: a physician-led platform that meets members at every step of their care journey, from a first question to the most complex care decisions," Tilton said. "Employers and health plans are under enormous pressure to manage the highest-cost, most complex members without compromising member experience. The Summus model directly addresses that challenge, and I'm excited to help bring it to more health plans and employer partners and members." This appointment reflects Summus' continued investment in building a world-class leadership team as the company scales its physician-led approach to clinical navigation and specialty care access.
Phoenix luxury home sales hit $173M as 8 properties eclipse $5M. May 14, 2026 Updated May 14, 2026 2:53pm MST Preview this article 1 min The latest period measured by the Business Journal marks the second straight week of elevated activity. Eight Valley homes sold for more than $5 million. Don't Stop Here - Continue Reading For $1 Per Week Secure 4 weeks of award-winning news and trusted insights Subscribe for only $4 Deadline: Friday, June 12, 2026 Healthcare Heroes Awards presented by BlueCross BlueShield of Arizona Do you know someone who is making a huge impact in Phoenix health care? Kenwoodmortgage need your help in recognizing the dedication and achievements of its local health care community.