Resp & Qualifications
PURPOSE: This position will select, develop, and manage processes to deliver, evaluate and continuously improve areas, which operate under several different Federal Employee Program (FEP®) Claims and Service systems. The QAA III is responsible for knowing Plan Incentive Program (PIP) guidelines, Blue Cross® Blue Shield® Association (BCBSA) guidelines and federal mandates. Participates on Corporate and/or FEP Projects to evaluate procedures and processes; to recommend and implement improvement to the way we do business. Supports FEP Bridge partner plans in the development and execution of training curriculum, claims and service manuals, and edit/deferral resolution tools.
Under the general direction of the Supervisor, the incumbent’s accountabilities include, but are not limited to the following:
1. Supports training and mentoring of new hires and operation associates on FEP Service, FEP Claims, Overseas and all systems that support these areas along with any new Corporate or FEP systems that become available. Prepare and present training presentations to all levels. Acts as trainer during class, when the trainer is absent. The QAA III trains the class and performs all the functions of the trainer. This would be on a limited basis.
2. Develop documentation specific to each plan that will utilize our FEP Bridge Solution. Creates and develops training curriculum, schedules and tracks attendance and analyzes effectiveness of training curriculum.
3. Development of in depth analysis to gain efficiencies and identify performance gaps to minimize financial risk to the organization. Identify procedural, system and training issues based upon audit findings and initiates resolution to these problems through recommending alternate procedures/processes and developing SOPs. Evaluates the effectiveness of current processes/procedures, techniques, systems and associates.
4. Performs monthly audits of all aspect of Operations and Technical support data analysis, reports, trends and recommendation. Participates and/or leads projects, workgroups, including those from upper CareFirst management (Directors Vice Presidents, Senior Vice Presidents.) and data base maintenance. Performs root cause analysis and creates action plan.
5. Serves as a subject matter expert for claims, service, overseas regarding claims adjudication, customer service procedures, medical policies, auditing practices, etc. Reviews, clarifies and/or interprets complex benefits and systems while utilizing all resources such as Administrative Procedures Manual (APM), Benefit Policy Manual (BPM), Blue Cross and Blue Shield Benefit Plan brochure, SharePoint, Blue Web, local and Op Center releases; provides information and decisions to operations. Coaching existing Quality Assurance Analysts in process improvement to gain efficiencies.
6. Identifies procedural, system and training issues based upon audit findings and initiates resolution to these problems through recommending alternate procedures/processes and developing SOPs. Evaluates the effectiveness of current training programs, processes/procedures, techniques, systems and associates. Conducts training and mentoring of new QAAs and operation associates.
7. Conducts internal consistency checks ensuring uniform and fair auditing practices throughout the department, across FEP.
• Five + years of the health insurance benefit/product and system knowledge
• Bachelor’s degree or equivalent work experience in a related field demonstrating knowledge of relevant functional areas such as contract law, operations/ service and claims, medical delivery, health insurance, health insurance product
• Has proven skills in coaching, mentoring and motivating associates. Must work with minimal supervision in a fast paced environment.
• The ability to manage multiple priorities simultaneously; project management
• Ability to travel to all CareFirst locations and other Bridge partner plans as needed.
Demonstrated the following:
• Proven judgment and decision making ability; must be able to make and carry out broad range of decisions while remaining consistent with the company and regulatory guidelines
• Ability to represent the department persuasively and articulately in meeting with other companies, departments, regulatory/insurance agencies and external clients and partners
• Effective written and oral communication skill
• Effective coaching skills
• Strong analytical ability, planning and problem skills
• Contributory participation in workgroups and/or projects
• Exceptional research ability
• Expertise in FEP products and benefits
• Effective planning and organizational skills
• Proficient in preparing reports, graphs, charts, trends and spreadsheets
• Exemplary attendance record
• Five + years of FEP auditing expertise
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: 4/11/2020
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