Resp & Qualifications
PRINCIPAL ACCOUNTABILITIES: Under the direction of Director, Compliance, Quality, and Process Improvement, the principle duties and responsibilities include, but are not limited to, the following:
- Designs, develops and implements quality assurance audit programs, across all major operational areas within the SBU. These programs correlate with the MTM and other BCBSA guidelines and CareFirst management direction for professional and productive efficiencies.
- Assures all stakeholders that the services of all affiliated organizations meet or exceed stated objectives and comply with relevant standards consistently.
- Performs root cause analysis and provides recommendations for improved business processes. This would include identifying weaknesses, inconsistencies, and inaccuracies in procedures, controls and system integrity. Provides high-level detailed, clear and professional performance feedback, department, directorate and SBU level quality standards in adherence to CareFirst Policies, SOP and protocols. Validates performance by focused audits and controls.
- Manages and directs information systems audits on benefits, claims files and electronic transactions to ensure systems functionality, reliability, and performance. Analyzes and evaluates Technical Support and strategies to identify opportunities for improved processes and outcomes and provide technical audit advice relating to system/operations.
- Reviews, clarifies and/or interprets customized/nonstandard benefit language in collaboration with the SBU Operations Technical Support team.
- Designs, develops and implements QA databases that will provide management and associates with information and diagnostic tools for further analysis and trending as well as scenario development and testing of new QA procedures and technologies and their impact.
- Develop and manage Operations/Technical support Quality Assurance Supervisors on audit protocols, documentation and trend analysis to report at an associate, system, department, directorate and SBU level in adherence to CareFirst Policies, SOP’s and protocols.
- Participates in assigned Operations meetings, committees and projects to advocate and demonstrate the ongoing implementation and measurement of quality assurance best practices.
- Keeps abreast of emerging issues and developments that have direct impact on the SBU.
- In collaboration with the Compliance team, manages the business processes across the SBU to model the current processes, identify improvement opportunities, and develop future process models to improve efficiency.
- Analyzes and recommends improvements for processes and identification of root causes; documenting this in a comprehensive and concise manner.
- Facilitates process redesign activities to model future state.
- Assists process stakeholders how in solving process challenges by simulating different scenarios, analyzing performance metrics and through optimization techniques.
- Provides consulting services on process improvements within a functional domain, evolving from information needs/requirements to documented processes.
- Supports business process optimization through mapping the business process requirements to IT possibilities
- Executes benchmarking of business processes. Researching and recommending industry best practices.
- Supports the SBU Compliance team in ensuring compliance and alignment with Federal, State regulatory statutes.
- Collaborates with the SBU Compliance team to research and support the corporate response in various regulatory and executive inquiries.
- Manage SBU Sarbanes-Oxley projects to: scope and document general control processes and automated business; perform risk assessments; identify key controls; evaluate design effectiveness of controls; and perform control walkthroughs.
- Design, develop and implement target audits in support of the compliance program.
- Participation in implementation/corrective workgroups as needed to ensure compliance via the quality audit program
- Monitors, assesses, and reports compliance matters to management.
Establishes and develops a dedicated team (direct reports and cross-functional teams) and process specializing in Quality Assurance, Business Process Development and Re-design to improve business processes.
Direct Reports: Quality Assurance Supervisors, Lead, Senior and Staff Auditors and Process Analysts.
- Bachelor’s degree in Business Administration or related field or equivalent directly related work experience
- 5+ years of managerial experience in Business Process Improvement, Customer Service, Quality Assurance, or similar focus.
- Must have strong leadership skills, proven analytical ability and a proven track record of managing multiple priorities.
- Experience in audit, project management, business process analysis, work flow, and task analysis
- In-depth health insurance operations knowledge/experience as well as an acute understanding of operations goals and objectives
- Thorough understanding and application of the principles and practice of internal/corporate audit
- Proven judgment and decision-making ability; must be able to make and carry out a broad range of decisions while remaining consistent with company and regulatory guidelines
- Strong facilitation expertise with experience and comfort with managing small to very large groups through complex concepts/issues
- Strong research and analytical ability, planning and problem-solving skills
- Excellent oral and written communications; able to communicate and present to management and associates at all levels throughout the Company
- Experience with working with stakeholders at various levels and functional areas.
- Must be able to manage and develop associates independently
- Must have the ability to follow instructions, to be flexible, to work independently with minimal supervision and to work as a member of a team.
- Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
- Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
- Experienced and proficient with Word, Advanced Excel and database management and related software applications
- Experience leading project teams and creating and managing scope, schedule and resources to deliver project on time, with in scope, and on budget
- Proven ability to capture customer business requirements and develop a concept of operations based off of the customers needs
- Experience providing executive level briefings to share results of accomplishments
The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The employee is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Travel is necessary to coordinate audit in both the DC and MD offices and other sites as required.
Department: Small Medium Service Business Unit - Audit Enhanced Portal
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 5/11/2018
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship