Job Details
Job Summary
Responsibility for completing accuracy reviews of case samples for program audits. Assesses operational and service performance of substantially all branded, core health business. The most common branded health lines of business included in the Program are: HMO, PPO, Indemnity, Traditional, Medicare Advantage, Medicare Supplemental products, Medicare Replacement products, and Medicaid. This includes ASO functions performed by the Plan. All services administered by the Plans that cover enrollment, claims and customer service must be measured and reported in accordance with the BCBSA Program Guides. Audit documentation utilized to report performance data should be stored for a minimum of ten years following the end of the reporting period. Staff are required to create screen shot packets and retain all transactions, policies, documents, etc., and be able to recreate the audit in its entirety if needed.
Responsibilities
1.Review transactions to ensure completeness and accuracy by using information available within the Plan for monthly case samples. Case reviews are done back to source documents which includes but is not limited to:
* Signed/Acknowledged group/member benefit contracts as well as at time the Sales Approved group benefit Product Configurator System
* Provider contracts for facility and professional services with review of specific detail on pricing requirements within the contracts (reading and assessing information within the contracts as defined by the various BCBSA Guide requirements)
* Pricing fee schedules for providers along with calculations for specific defined pricing polices for varying types of services, assessment for pricing detail is from sources in the plan prior to any upload to the processing system
* Understanding and reading data files (i.e., HIPAA 837/834) from groups and providers for member and claim details to assess the processing systems are accurately reflecting the details submitted
* Provider data demographics from provider credential documents, provider portals, letters, phone calls to providers or other sources in the provider network business area
2.Auditing against the methods and requirements as deemed compliant by the various BCBSA Program Audit Guides.
3.Creating audit packet documents as our plan's internal source for evidence of what was reviewed during the sample case assessment. Packets include screen shots of all source documentation assessed at the time of the case review and any pertinent IBC policy provisions that are part of the case determination as defined in the program requirement guides
4.Monitor deadlines and serve as a technical liaison when appropriate for sample transaction questions
5.Assess regulations for compliance of audit reviews per program audit guidelines, required data sources and incorporate what is required into the specifications and/or documentation
6.Identifies trends related to findings, reports audit outcomes as needed to related business units, and support or implements enhancements based on results with appropriate personnel
7. Tracks pended case issues and makes recommendations for improvements
8.Communicate effectively in writing and verbally with in work groups and internal and external customers
9.Attend internal and external education training to achieve and maintain proficiency on all systems
10.Meet required audit deadlines and quality standards
Education
Associate degree or 3-5 years equivalent work-related experience around claims detail, Bachelor's Degree preferred
Experience
Auditing practices and methodologies
Knowledge, Skills, Abilities
Knowledge of systems related to Claims adjudication or Enrollment practices or Inquiry transactions for processing practices, and timelines to ensure handling of cases comply across operational disciplines.
Ability to compile detailed documentation, and data mining to support audit requirements. Skilled in trend analysis and effective in communicating as the liaison with business partners on findings and recommendations focused on minimizing impacts to other areas and the customer.
Strong written and verbal communication skills are required as well as attention to detail when reviewing transactions.
Maintain flexibility in a team environment, escalate findings to management and identify process improvement opportunities and trending.