Performs audits in accordance with BCBSA, State and Federal guidelines, client contracts, corporate policies and procedures and regulatory mandates.
Audits are performed for all company branded product lines. Audit scope includes but is not limited to the three primary operational areas: claims payments including high dollar pre-paid claims
Auditing is also performed on EHP claim processing vendors, PFM transactions and Provider partnership facilities. Additional free-standing claim systems audited are PBM vendor systems, FEP Direct Operations system and the Dental claim processing system.
Audits require evaluation and research to obtain pertinent claim information including contacting physicians, facilities, groups, subscribers, and other insurance companies. Additional requirements are accurate interpretation of member and provider contract language to ensure appropriate application of benefits.
Remains current with relevant legislative and regulatory mandates to ensure activities are in compliance with these requirements. Also, be aware of all local, regulatory, operational, and national policy changes.
Adheres to and meets established deadlines as required by management.
Document monthly work and performance measures. Proposes recommendations for system enhancements, workflow modifications, processing guidelines, system documentation and/or training documentation.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Analyzes performance data, identifies trends, and raises questions regarding policy interpretation throughout all areas of the company.
Discusses observed inconsistencies and errors with management to identify root causes of errors, verifies findings, communicates results, and initiates payment recovery/reimbursement and acts in a consulting capacity to ensure that remediation plans are accurate, effective and timely
Performs consulting duties that improve operational effectiveness and assist in the development or modification of processing guidelines, workflow modification, system enhancements and system documentation to improve operational reliability and efficiency.
Prepare complete and consistent work papers to document inconsistencies and calculate results for each performance measure using but not limited to Excel and Access.
Strong verbal/written communication skills
Understands, enforces, the use of policies and procedures through auditing.
Coordinates specific audits such as, but not limited to MTM, LDLA, payroll or external audits from beginning to end including data compilation.
Has audited claims in the past of $250,000 and above.
