Resp & Qualifications
Purpose: The Senior Auditor 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 incumbent is considered a Subject Matter Expert (SME) in their audit field with proven auditing results and provides a comprehensive analysis of transaction, systems and procedures while also providing coaching and mentoring to all levels of associate. The Senior Audit Position has attained the knowledge and experience required to perform high level specialty audits such as member self-service system reviews, Other Party Liability department audits, targeted specialty claims audits, and Summary of Benefits and Coverage (SBC) Audits. The QA Senior Auditor will also develop and manage processes to deliver, evaluate and continuously improve all areas of the SBU including the creation and distribution of reports to appropriate SBU management and associates. The Senior Auditor will work with SBU management to establish and implement corrective action plan as an outcome of any audit findings.
Under the Senior 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 Senior Auditor also works on special targeted audits outside of the standard associate audits.
The QA Senior 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 Senior Auditor also assists in 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 Senior Auditor will perform all necessary follow-up activities related to audits errors to ensure that corrective action have been appropriately taken.
Adheres to all departmental quality standards.
2. Coaching and Knowledge Expert
Provides coaching and mentoring to audited customers on a monthly basis and is considered a go-to resource on SBU transactions. 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 Senior Auditor is 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. Analyzes, 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. The incumbent will exhibit a level of mastery and is considered a go-to resource on SBU Operational transactions, typically garnered after years of hands-on experience.
Participate in training within the SBU Quality Auditing Department with the goal of learning the Lead Auditor’s accountabilities.
3. Audit Process Creation and Enhancement
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 proposes solutions to improve results. Conducts training & mentoring of new auditors and operational associates. Serves as a resource in the creation of technical job improvement publications to be released to all operational areas and in some cases is the sole author.
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 Senior Auditor will assist in performing technical system and platform user acceptance testing while working with the OTS and TOS areas. This includes testing that 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 the 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.
Distribution of Accountabilities:
• Five + 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.
• Must work with minimal supervision in a fast paced environment.
• The ability to manage multiple priorities simultaneously.
• 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
• Three + 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: 7.8.21
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
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