Lead Quality Assurance Consultant (Claims)

Job ID: J118815
Company: Highmark Health
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 21, 2018

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Description

JOB SUMMARY

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.

ESSENTIAL RESPONSIBILITIES

  • 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.

EDUCATION

Required

  • Bachelor's Degree in Business Administration/Management, Accounting,
  • Health Administration or General Studies

Substitutions

  • 6 years relevant experience in lieu of degree

Preferred

  • None


EXPERIENCE

Required

  • 7 - 10 years Audit and Compliance

To Include

  • 5 - 7 years Project Management
  • 3 - 5 years Operations and/or Business Analysis

Preferred

  • None

SKILLS

  • Auditing
  • Claims Processing
  • Customer Service
  • Billing Systems
  • Benefit Coding
  • Enrollment Systems

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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