Resp & Qualifications
PRINCIPAL ACCOUNTABILITIES: Under the direction of the Manager, Quality Assurance, the following shall include but not be limited to:
- Design, develop and implement quality assurance programs, which coordinate with MTM & BCBSA guidelines, using the principles of Six Sigma/ DMAIC methodologies, and other technologies, across all CareFirst Operations. Design, develop and validate quality assessment criteria and appropriate statistical sampling methodologies. Ensure quality auditor associates comply with documented auditing processes including, but not limited to, audit schedule adherence and appropriate documentation of audits. Select, train, coach and assess quality auditor associates and develop individual associates and department team capacity to meet and improve upon required productivity, line support and quality standards of the department Assure all stakeholders that the services of all affiliated organizations meet or exceed stated objectives and comply with relevant standards consistently. Act as a liaison between MTM and Operations to develop action plans. Lead company wide 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. Provide vendor oversight by conducting audit support and develop action plans to improve service. Attend all external audit meetings with clients for High Risk Accounts. Deliver presentations to VP and Senior VP level on a regular basis.
- Develop and manage Quality Assurance staffs on audit protocols, documentation and trend analysis to report at an associate, system, department, directorate and divisional level in adherence with CareFirst Policies, SOP’s and protocols. This would include identifying weaknesses, inconsistencies, and inaccuracies in procedures, controls and system integrity. Perform root cause analysis and provide recommendations for improved business processes. Develop action plans and follow up with core business leadership teams through director, manager and supervisory level meetings. Support business areas including Claims Business Analysts, System Benefit Coders, Contract Specialist, Operations EAB, and Claims & Service for definitive interpretation of BCBSA polices and CareFirst protocols. Normalizes HMO, Member & Provider audit processes and workflow due to FLEXX/FACETS platform company transition. This is inclusive of all Operations Service platforms and functions. Direct and conduct information systems audits on Benefit and Claims files (i.e. BEI & OBN) to ensure systems functionality, reliability, and performance. Analyze and evaluate 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. Provide support to Sales, Marketing, and Underwriting & benefit coders on all system platforms. . Provide vendor over site by conducting audit support and develop action plans to improve service. Attend all external audit meetings with clients for Performance Accounts.
- Work with Quality Assurance & Training and in conjunction with Corporate Audit, Medical and other divisions within CareFirst to analyze, trend and produce action plans to support our internal and external customers with quality improvement efforts. Act in a consultant role with other departments in the development, editing and preparation of SOP’s and forms in accordance with organizational policies and regulations. Participate in appropriate and assigned Operations meetings, committees and projects to advocate and monitor the implementation and measurement of quality assurance best practices. Design, develop and implement 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.
SUPERVISORY RESPONSIBILITY: This associate will directly supervise up to 23 associates
- 1-3+ years of supervisory experience
- 6 years of health insurance benefit/product, system knowledge (indemnity and/or HMO)
- Bachelor’s degree or equivalent work experience in a related field demonstrating knowledge of relevant functional areas such as operations (service and claims), benefit delivery and health insurance products
- Demonstrated leadership skills
- Excellent proficiency within the service, claims and enrollment & billing operational unit
- Thorough understanding and application of the principles and practices of internal/corporate audit
- Service and/or claims reviewer experience
- Leads workgroups involving MTM or other quality assessment protocol and business quality systems
- Proven skills in coaching, mentoring and motivating associates
- The ability to manage multiple priorities simultaneously by utilizing project management skills
- Ability to produce and deliver senior level management presentations using reports, graphs, charts, trends and spreadsheets
- Ability to use different statistical data sources to produce reports and feedback systems leading to root causes
- Must be able to manage and develop associates independently
- Must be able to analyze business information and develop recommendations and action plans
- Demonstrated interpersonal skills
- Use of statistical software systems
- 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
- Ability to represent the department articulately during interaction with management, vendors, other organizations, regulatory/insurance agencies and external clients and partners
- Ability to lead workgroups, analysis and/or projects
- Excellent written & oral communication and coaching skills
- Strong research and analytical ability, planning and problem solving skills
- Expertise in CareFirst products, benefits and managed care procedures
Department: SBU Quality Assurance- DC
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: 10/05/2019
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.
PHYSICAL DEMANDS: The employee is primarily seated while performing the duties of this position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls or objects. The employee must frequently talk, see and listen. Weights of up to 25 pounds are occasionally lifted.
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.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship