Awarded the Best Place to Work 2021, Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
This remote work opportunity requires residency, and work to be performed, within the State of Arizona.
PURPOSE OF THE JOB
* Responsible for developing audit programs and services to assist with achievement of goals and initiatives. Responsible
for conducting audits and reviews to ensure standardization, consistency, and compliance are maintained across
Connercial and Government lines of business. Coordinate training of new auditors. Coordinate new projects related to
changes and enhancements within BCBSAZ systems that impact supported departments and processes.
1. Required Work Experience
* 2 years in healthcare production area.
* 1 year of medicare experience, preferably in managed care.
* 2 years of coding/claims experience.
2. Required Education
* Bachelors degree in business, healthcare, or technology related fields.
3. Required Licenses
4. Required Certifications
1. Preferred Work Experience
* 5 years of experience in auditing and business analysis.
* 2 years work experience in a managed care setting
2. Preferred Education
3. Preferred Certifications
4. Preferred Certifications
ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES
* The Quality Solutions Auditor is responsible for supporting the UM vendors and internal auditing programs which includes
employee audits as well as additional internal audits. . This includes monthly calibration audits (or more frequent per
business need), administrative review of policies and procedures for Health Plan UM Vendors, Plan Partners, and other
entities, if necessary, to ensure compliance with vendor contract and collaborate with compliance and Quality teams on
local, State, Federal, CMS and National Committee on Quality Assurance (NCQA) regulations, statues and guidelines.
* Preparing the audit findings, documentation of deficiencies as well as developing final analysis reports for internal and
external UM Department Leadership.
* Eligbility to interpret Service Level Agreements within an Exulted Contract with Vendor and audit according to quality and
quantity of contract.
* Monitor corrective action plans to address deficiencies identified by conducting program audits and collobarate with
Business Partner Outsourcing.
* Conducts monthly audits to measure documentation quality, performance and compliance. Audits include regulatory and
procedural components. Collaborates with UM leadership to implement and monitor individual CAPs and/or PIPs as
* Work with analytics and data science teams to build processing error reports.
* Work with department managers and leads to make corrections in documentation, review monthly audit performance
results, and drive quality of processing improvements.
* Work with traininers to update documentation for all relevant policy and procedures, desktop procedures, and any other
relevant documents used by vendor(s) for ongoing processes
* Work with the appropriate area management to develop and implement monthly, quarterly and YTD reporting processes
to track and measure goals and productivity.
* Maintain and modify, as necessary, any existing reports and new reports as needed to analyze data; perform root cause
analysis to identify potential issues.
* Function as the process expert to assist management with emerging challenges and measurement needs.
* Performs independent high level and detailed analyses to identify patterns and trends that do not support desired results
and be able to convey results of research or analysis to all audiences and answer all questions.
* Perform analysis and provide necessary business requirements to support changes to any reporting.
* Define and establish business rules and data measurement policies. Provide education of these policies to internal
customers and vendor(s).
* Responsible for URAC Delegation Analysis and ongoing reporting. Maintain URAC Training Documentation.
* Demonstrate and maintain current working knowledge of the required BCBSAZ systems, procedures, forms and manuals
* Develop and maintain audit training documentation or provide necessary support and input to areas supporting training
* Work with internal areas to develop and coordinate materials for webinars as requested by management.
* Work with internal BCBSAZ departments on educational material and coordination of their deliverables.
* Responsible for staying abreast of product/member/provider issues, legislation, CMS mandates, policy changes and
system changes so they can be considered for audit training topics and enhancements.
* Act as a "change agent", constantly challenging conventional thinking, approach, and ways of performing processes.
* Perform root cause analysis to identify continuous process improvements and to improve customer satisfaction.
* Demonstrate initiative and resourcefulness in achieving goals and tasks as related to the divisions objectives.
* Meet deadlines in required timeframe established by management.
* Actively participate in the employee engagement process.
* The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. * Perform all other duties as assigned.
1. Required Job Skills
* Strong written and verbal communications. Excellent organizational skills and strong attention to detail
* High level of personal accountability and integrity.
* Self-motivated and able to work with minimal direction and exercise sound judgment.
* Ability to gather, analyze data and prepare informative and accurate reports.
* Ability to understand the workflow of multiple components of the company and to assist in the creation and
implementation of integrated policies, procedures, workplans and creative solutions.
* Intermediate skill in use of office equipment including copier, fax machine, scanner and telephones
* Advanced PC proficiency
* Advanced word processing, excel, Tableau, and database software.
2. Required Professional Competencies
* Ability to develop, organize, motivate, coordinate and collaborate effectively with stakeholders from multiple business
areas across the organization
* Ability to successfully function in an environment characterized by risk taking, rapidly changing market conditions,
strong competition and restructuring.
* Organizational skills to analyze, interpret data, synthesize, evaluate and explain educational concepts, practices and
methodologies to staff and transfer data to and from written and verbal medium.
* Ability to maintain confidentiality and privacy
* Practice interpersonal and active listening skills to achieve customer satisfaction
* Demonstrated organizational skills with the ability to priortize tasks and work with multiple priorities
* Follow and accept instruction and direction
* Establish and maintain working relationships in a collaborative team environment
* Apply independent and sound judgment with good problem solving skilll
* Interpret and translate policies, procedures, programs and guidelines
3. Required Leadership Experience and Competencies
* Desire and capability to drive toward and achieve high standard of quality and results.
* Mindset geared toward the creation, execution and continuous improvement of the Clinical Benefit Management
Solutions department and programs. Intellectual curiosity and ability to view old problems/issues with a fresh
* Ability to perform job role duties independently.
* Ability to professionally represent BCBSAZ in the community
* Use available information to focus conversations and meetings
* Use facilitator skills to move a group or team from beginning to end of a process
1. Preferred Job Skills * Advanced PC proficiency * Advanced Excel, Word, Powerpoint * Intermediate Tableau * Knowledge of CPT/HCPCs and ICD-10 coding
2. Preferred Professional Competencies
* Knowledge of managed care, utilization management, and quality management
3. Preferred Leadership Experience and Competencies
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.