This job is the Subject Matter Expert (SME) over Claims and is accountable to ensure that all audits of the function are compliant for each audit program or contractual requirement. It is critical that the incumbent possess a high degree of operational expertise and knowledge of the Claims process in addition to the insurance industry. It is preferred that the incumbent have mastery of Highmark systems, business processes, and organizational structure.
- Project management which includes participation in all customer project implementation teams to understand new processes and new data. Function as a lead for projects and/or focused audits consistently meeting or exceeding all project goals. Write Use Cases / Requirements for new functionality to meet customer needs. Perform user acceptance testing on specific audit components. Participate in Perform tasks related to HMA, and Dashboard testing, as well as provide support for external audits, SSAE16, etc., as required. Define proper prioritization for Root Cause Error Resolution efforts.
- Knowledge management and training which includes creating and maintaining detailed audit process documentation and checklists and ensuring compliance with BCBSA, MTM, NCQA, FEP, LDLA, Medicaid, CMS as well as contractual Performance Guarantees and other focused improvement effort guidelines. Perform gap analysis which will be utilized to prepare and deliver training to front line staff, other resources performing audit functions as well as partner plans as needed. Perform on-boarding tasks for internal and OS staff including providing system and process demonstrations and walk-throughs.
- Customer engagement and relationship management which includes participating and/or leading meetings as well as taking part in rotational opportunities with Customer Operations to fully understand culture and needs. Maintain a thorough understanding of operational procedures and systems within the process being audited. Anticipate customer needs and outline proper insights from reporting (monthly/quarterly). Seek feedback from customers via surveys and work to correct deficiencies.
- Perform a complete review and analysis of complex transactions as required by BCBSA, MTM, NCQA, FEP, LDLA, Medicaid, CMS as well as contractual Performance Guarantees and other focused improvement efforts to determine accuracy and compliance with guidelines and contractual obligations.
- Other duties as assigned.
- Bachelor's Degree in Business Administration/Management, Accounting,
- Health Administration or General Studies
- 6 years relevant experience in lieu of degree
- 7 - 10 years Audit and Compliance
- 5 - 7 years Project Management
- 3 - 5 years Operations and/or Business Analysis
- Claims Processing
- Customer Service
- Billing Systems
- Benefit Coding
- Enrollment Systems
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