Resp & Qualifications
The incumbent performs and participates in the completion of validating the accuracy of experiences by members of CareFirst, Inc. on branded services in accordance with the Member Touchpoint Measures Program (MTM) and Licensee Desk-Level Audit (LDLA). guidelines issued by the BlueCross BlueShield Association (BCBSA). The performance auditor will perform and participate in the completion of validating the accuracy of MTM and LDLA Home audits. The audit results are reported to the BlueCross BlueShield Association as a part of a Licensee standard for all BCBS plans to protect the brand name of BlueCross BlueShield. The measures audited are designed to determine the efficiency and effectiveness of CareFirst, Inc.'s internal operations areas, which have a direct impact on CareFirst, Inc.'s individual customers, accounts, and the overall cost of care incurred by the organization. The results are also reported to Executive Staff and Operations Management and are a component of the Commercial Strategic Business Units’ (SBU) Annual Incentive plan.
Analysis of this performance of the operational departments assists in identifying potential areas of risk that may impact both our providers and subscribers. Upon identification of those risk factors, corrective action plans can be implemented by the SBU Management team to remediate the inefficiencies of both the systems and processors within those departments. As a representative of the department, the candidate will perform any audit within the BCBSA Auditing Department, Quality Assurance Departments, or as requested by the CareFirst Executive Management team. Additionally, the incumbent will have frequent interaction with the following SBU and internal departments: Claims, Customer Service, Enrollment and Billing, Contracting, Quality Assurance & Training, Networks Management, Provider, Contracts and the Special Investigations Unit.
Under the general guidance of the Manager of BCBSA Auditing and direct supervision of the Supervisor the incumbent’s accountabilities include, but are not limited to, the following:
1. Audit Validation
Reviews MTM and LDLA Home errors on a regular basis to identify and research issues trend analysis and provide recommendations for corrective action, system and procedure modifications and enhancements to improve service and quality procedures.
• Assist with performing detailed targeted audits to further explore potential error trends as needed under the guidance of the Data Analyst, Lead Auditor, Senior Auditor and Supervisors
• Perform subsequent follow up on all audit findings with the appropriate SBU’s for manual or system corrections/adjustments as required.
• Ensure discrepancies are appropriately identified and errors assessed per MTM and LDLA guidelines prior to management involvement.
• Alert senior management of any auditing discrepancy disagreements encountered with the SBU’s.
• May be assigned additional or asked to perform auditing to drive completion of all auditing activities to assure monthly reporting of MTM scores are met per defined schedule, and within BCBSA deadline.
• This includes auditing on multiple systems/platforms such as: FACETS, NASCO, and CFA.
• May also assist with performing accuracy audits of the Blue Card Host claims in accordance with Licensee Desk-Level Audit (LDLA), which include specifically the NASCO and Inter-Plan Teleprocessing System (ITS) systems.
2. Project Coordination
Identifies weaknesses, inconsistencies, and inaccuracies in procedures, controls, and system integrity related to MTM, and LDLA systems. In concert with SBUs assure CareFirst is prepared for changes to the BCBSA MTM and LDLA programs, and that the overall score continues to improve, ultimately meeting the established annual SBU targets by assisting with coordination, and project support.
• Assist with system and Product Focused Audits in accordance with CareFirst Contract and system coding to validate accuracy with MTM guidelines.
• Assist with follow-up activities related to audits/reviews, special projects, and other duties as assigned to ensure corrective action have been appropriately taken.
• Review audit findings with both the SBU’s and Management staff to ensure audit findings are accurate, fair and agreement achieved.
• Participate in meetings and presentations as a representative of the MTM Audit Performance Audit Department.
3. Training and Development
Ensure that training goals are met per MTM department guidelines
• Participate in training with the goal of increasing MTM knowledge across all systems and measures i.e., claims, inquiry, membership and group per the MTM program
• Continuously strive for excellence and identify the changing needs of internal and external customers while seeking additional development opportunities to enhance skills and abilities.
• Minimum of 4-6 years Auditing, Quality Assurance, Operations, Training, Project Management or comparable work experience
• Strong knowledge of claims, inquiry and enrollment processing on multiple platforms such as (FACETS, NASCO, CFA, LDLA) preferred
• Standard knowledge of Quality Audit processes and reporting requirements
• Strong PC skills (Microsoft Outlook, Word, Excel, PowerPoint)
• Strong knowledge and ability to interpret data screens within multiple CareFirst internal systems such as: FACETS, NASCO, LDLA and CFA preferred
• Ability to read and interpret contracts
• Ability to research and document audit issues
• . Knowledge of statistics; familiarity with statistical measures
• Strong decision-making ability and interpersonal skills
• Excellent communication skills (verbal and written) with the ability to influence and effectively communicate with all levels of associates and management
• Ability to participate and/or facilitate problem-solving discussions and negotiate effective solutions of audit issues
• Ability effectively manage MTM workload with competing priorities with adherence to department goals and deadlines
• Ability to perform accuracy audits on multiple systems and measures such as (Inquiry, Claims, Membership, and Group) in accordance with the MTM Program guidelines.
• Professional attitude & professional attire required
• 4+ years of experience as a Business Analyst, Quality Assurance analyst or comparable work experience
• B.S./B.A. degree
MTM - MD
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: 10/25/2019
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.
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 and handle small controls and objects. The employee must frequently talk, hear and comprehend. 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 principal accountabilities 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