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Resp & Qualifications

PURPOSE:

Responsible for systematic investigations of a specific area of operations (i.e., claims, customer service, enrollment) within the organization. Incumbent conducts a variety of audit activities which may include, but not be limited to, process audits where there is a technology component, operational audits involving internal and/or external process and procedures, and audits of vendors/partner contracted services. In addition, the incumbent is responsible for ensuring QA testing is thorough and accurate in ensuring the audits under review adhere to company policies and procedures, audit methodologies, BCBSA guidelines and all applicable regulations. Serves as subject matter expert and resource to junior staff.

ESSENTIAL FUNCTIONS:

+ Serves as the subject matter expert for Quality Assurance area. Perform quality assurance audits to investigate all aspects of the systems and/or procedures in place to ensure consistent and reliable product quality. Review the official lines of authority put in place to drive Q/A initiatives, the systems put in place to continually drive product quality higher and the monitoring of systems and/or procedures used to review the effectiveness of Q/A efforts. Lead and participate in the completion of validating the accuracy of audits accordance with established guidelines. This position will also lead efforts related to other internal/external audits and quality assurance programs in support of corporate programs. Lead activities to document and convey operational requirements to proactively enhance outcomes.

+ Perform follow-up activities related to audits/reviews and special projects thus ensuring that corrective action have been appropriately taken. Provides coaching/mentoring to more junior auditors members and provide guidance on complex work efforts. Assist with special projects and/or departmental initiatives that require subject matter expertise in a consultative manner. Monitor operations and test outputs to ensure consistent quality by identifying errors and opportunities to improve. Review audit findings with both the assigned client group and leadership to ensure audit findings are accurate, fair and agreement has been achieved. Perform subsequent follow up on all audit findings with the assigned client group for manual or system corrections/adjustments as required. Advise leadership of any disagreements or noncompliance to these requirements.

+ Submit audit findings to assigned client areas and leadership that outline the root cause of identified issues as well as provide recommendations for corrective action, system and procedural modification and enhancements to improve service and quality. Issues may include, but are not limited to: weaknesses, inconsistencies and inaccuracies in procedures, controls and system integrity. Compile, analyze and report any fraudulent activity or information to the appropriate departments. This information or activity may represent a potential risk to the organization, its subscribers, accounts and providers.

SUPERVISORY RESPONSIBILITY:

Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.

QUALIFICATIONS:

**Education Level:** Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

**Experience:** 5 years Auditing experience.

Knowledge, Skills and Abilities (KSAs)

+ BlueCard

+ Proficient in quality audit processes and reporting requirements.

+ Strong PC skills (Microsoft Outlook, Word, Excel, PowerPoint).

+ Extensive analytical and problem-solving skills.

+ Strong decision-making ability and interpersonal skills.

+ Ability to prioritize multiple tasks and meet critical deadlines.

+ Demonstrated skills conducting problem-solving discussions to negotiate effective solutions to audit issues.

+ Knowledge of all claims, service and enrollment processing systems.

+ Excellent communication skills (verbal and written) with the ability to influence and effectively communicate with all levels of associates and management.

+ Ability to provide guidance and leadership to less experienced team members.

+ Good working knowledge of mainframe programs.

+ Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

**Salary Range:** $66,672 - $132,418

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

BCBSA Performance Audit

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.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

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 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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REQNUMBER: 21266