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Resp & Qualifications
Purpose: This advanced-level auditor position will work in collaboration with the Supervisor and Manager of the Strategic Business Unit (SBU) Quality Assurance department in performing in-depth system and procedural audits of all Operational Areas in the SBU. The audits are designed to determine the efficiency and effectiveness of the SBU’s internal operations areas. The Lead Auditor will conduct regular reviews and audits of internal controls within each functional area for strengths and weaknesses ensuring special focus to the specific risk areas. Upon identification of those risk factors, the Lead Auditor, in collaboration with Quality Management, recommends corrective action plans to be implemented by Management to remediate the inefficiencies of both the systems and processors within those departments. The incumbent is considered a Subject Matter Expert (SME) in their audit field and provides a comprehensive analysis of transaction, systems and procedures while also providing coaching and mentoring to all levels of associate. The QA Lead Auditor will also develop and manage processes to deliver, evaluate and continuously improve all areas of the SBU. They will also create, analyze and publish reports on the outcome of certain audits performed. The Senior Auditor will work with SBU management to establish and implement corrective action plan as an outcome of any audit findings.
Under the Lead Auditor Position
1. Core Auditing Processes
Performs monthly audits of all aspects of Operations and provides technical support, data analysis, reports, trends and recommendations. Participates in root cause analysis and creates action plans using established methodologies. The Lead Auditor will also perform specific targeted audits and ad hoc audits of intricate processes. Creates and publishes several auditing reports utilized by the QA team for day to day operations.
The QA Lead Auditor provides detailed audit results and analysis of error trends with the ultimate goal of improving the customer performance and accuracy in all operational areas. Proactively schedules and supports corporate special audits for root cause and fiduciary/expense avoidance situations. The auditor is responsible for knowing external requirements including BCBSA guidelines (including but not limited to MTM and Blue Card), federal and state mandates, as well as account contractual requirements, including performance standards. Conducts Root Cause and Frequency analysis to identify opportunities for improvement to systems and business processes. The Lead is also the principal contact for all ad hoc questions that are received from QA management. The Lead Auditor also leads the review and documentation of new procedures introduced to the auditing team.
After error research and analysis, the auditor will pursue remediation through numerous channels including SBU operational areas, the TOS division, the Facets Benefits Team, Medical Management and the Special Investigations Unit.
The QA Lead Auditor will perform all necessary follow-up activities related to audits errors to ensure that corrective action have been appropriately taken.
The Lead Auditor will also provide a consultative role to the SBU QA management in the review of audit appeals and new processes, as well as offering recommendations of proposed changes that improve operational outcomes. Proactively completes research, analyzes outcomes, and makes recommendations of audit improvements to Sr. Quality Management.
Adheres to all departmental quality standards.
2. Coaching and Knowledge Expert
Provides coaching and mentoring to audited customers on a monthly basis. This includes face-to-face or telephonic error review/feedback sessions with those audited as well as chair side auditing of live transactions as needed. The Lead Auditor can provide coaching and/or training to any level of management if needed. The Lead Auditor is also able to audit more complex transactions typically associated with targeted specialty audits that require an experienced auditor.
Serves as a subject matter expert for all previously mentioned operational areas by providing technical expertise regarding claims adjudication, customer service procedures, medical policies, auditing practices, etc. Reviews, clarifies and/or interprets complex customized/non-standard benefit requests; provides information and decisions to operations (Sales, Business Analysts, Executive Inquiry, E&B Techs, etc.). Coaching existing auditors in process improvement to gain efficiencies. Reviews and analyzes MTM discrepancies in comparison to internal audit findings to better identify trends. Provides consulting advice to QA management on a wide variety of ad hoc issues that occur such as appeal resolution. The incumbent will exhibit a level of mastery providing coaching and mentoring to all audited subjects and is considered a go-to resource on SBU Operational transactions, typically garnered after years of hands-on experience.
3. Audit Process Creation and Enhancement
Development of in-depth analysis to gain efficiencies and identify performance gaps to minimize financial risk to the organization. Identifies procedural, system and training issues based upon audit findings and initiates resolution to these problems through recommending alternate procedures/processes and developing and evaluating SOPs. Evaluates the effectiveness of current processes/procedures, techniques, systems and associates and makes recommendations based on analysis. Conducts training & mentoring of new auditors and operational associates. Creates technical job improvement publications to be released to all operational areas.
4. Project Review and Process Oversight
Participates on and/or leads projects, workgroups, including those from upper CareFirst management (Directors, Senior Directors and Vice Presidents). This includes implementation of new regulations and guidelines as well as testing of new systems and applications. Conducts internal consistency checks ensuring uniform and fair auditing practices throughout the department, across all lines of business. Reviews and analyzes error trends to provide reporting to improve results.
The QA Lead Auditor is a systems technical expert particularly on proprietary auditing software. This includes the maintenance of the system as well as writing detailed technical requirements for programmers to enhance the system as well as providing help desk support for all users inside and outside of the SBU.
The Lead Auditor works in concert with OTS and TOS areas to perform technical system and platform user acceptance testing. This includes working with Business and Functional Analysts in all operational areas to ensure proposed system changes are working correctly and have no negative downstream affects to audit and operational processes. It also includes the full review and analysis of new and existing metric reports that are required for day-to-day audit operations as well as ad-hoc analysis of specific identified issues.
The incumbent’s accountabilities include, but are not limited to the operational functions in Enrollment & Billing, Claims, Service and System & Benefits.
• Seven+ years of health insurance benefit, product, medical and system knowledge/experience. 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
• Must possess extensive and in-depth CareFirst Blue Cross Blue Shield technical knowledge, such as Claims processing, Customer Service or Enrollment and Billing.
• Has proven skills in coaching, mentoring and motivating associates as well as leadership skills. Must work with minimal supervision in a fast paced environment.
• The ability to manage multiple priorities simultaneously; project management
• Ability to travel locally within the DC/MD/WV and outside local service area when required. (Specific requirements are dependent on the SBU.)
• Working knowledge of Microsoft Windows and Office applications.
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 CareFirst products and benefits, managed care procedures
• Effective planning and organizational skills
• Ability to prepare reports, graphs, charts, trends and spreadsheets
• Five+ years of auditing expertise (indemnity and/or HMO).
• Working knowledge of Facets system, Blue Card and claims adjustments experience. Other systems utilized: Verint, TRMS, SIR, HPX, Pega, Claim Check, Pricer, Medical Policy Reference Tool, Facets Policy Reference Tool, Broker Express, Business Objects, Rubi, eBiz, and Blue2/ITS, NASCO, CF Direct, Member’s Edge & Portico (dependent on specific SBU)
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: 6/21/2020
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