Quality Assurance Analyst - Audit-2

Job ID: J133202
Company: Highmark Health
Location: Wilmington, DE, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Oct 8, 2018

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Description

JOB SUMMARY

This job performs transactional quality audits and tasks in compliance with BCBSA, MTM, NCQA, FEP, LDLA, Medicaid, CMS Guidelines as well as contractual Performance Guarantees and other operational quality process improvement efforts. Maintains accurate audit documentation and are required to follow appropriate audit guidelines as well as department and Corporate policies and procedures.

ESSENTIAL RESPONSIBILITIES

  • Perform a complete review and analysis of transactions as required by BCBSA, MTM, NCQA, FEP, LDLA, Medicaid, CMS as well as contractual Performance Guarantees and other operational quality efforts to determine accuracy and compliance with guidelines and contractual obligations.  Possess a thorough understanding of operational procedures and systems within the process being audited.   Manage individual inventory of audit work to meet department quality standards. Participate in special project work as needed.
  • Effectively utilize HMA application (audit tool) to manage audit case inventory, document audit samples and describe and support audit findings and communicate them to internal and external customers as appropriate. Obtaining source documentation, validating it is accurate and complete in compliance with guidelines and reporting requirements.   Maintain scorecard entries in HMA accurately and consistently meet all production standards established in departmental protocol. 
  • Monitor various mediums to ensure awareness of most current information available via the Knowledge Center and other resources to apply to auditing determinations. Share relevant information with the team when received individually through normal work channels.
  • Other duties as assigned.

EDUCATION

Required

  • High School Diploma/GED

Substitutions

  • None

Preferred

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

EXPERIENCE

Required (one or more of the following)

  • 3 - 5 years in Claims Support and Processing
  • 3 - 5 years in Customer Service
  • 3 - 5 years in Billing
  • 3 - 5 years in Enrollment
  • 3 - 5 years in Benefits Administration

Preferred

  • None

LICENSES AND CERTIFICATIONS

Required

  • None

Preferred

  • None

SKILLS

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

Language (Other than English)

None 

Travel Required

0%  - 25%

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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