Quality Auditor - QUA0000B
DESCRIPTION/RESPONSIBILITIES:
This position is responsible for auditing samples of claims, inquiries and enrollment transactions in order to determine if they were processed correctly according to MTM, BCBSM, FEP or account guidelines. For all identified errors, notifies responsible departments and conducts follow-up to verify correction.
* Review and analyze claims, inquires, and enrollment transactions to verify they were processed accurately and completely.
* Document review results and assist Senior Quality Auditor in the development of error trend analyses.
* Participate in error disputes and calibrations with the operating areas.
* Classify errors by cause or type based on departmental guidelines and participate in special projects as assigned.
* Monitor telephone calls and notify operational areas of all identified errors and rationale for assigning errors.
* Verify member and provider eligibility, pricing and benefits in compliance with BCBSM payment rules for claims payments.
* Assess the nature of the inquiry and ensure the response and/or adjustment was complete and accurate.
* Maintain knowledge of MTM, LDLA (Blue Card), and FEP reporting requirements, statistical sampling techniques, BCBSM and BCN corporate policies and procedures, benefits, eligibility, core business and related systems and processes (claims, membership, inquiries, medical policy, pricing, etc.) as well as applicable laws and regulations (i.e. PA 350, HIPAA, DOL/ERISA, etc).
* Other duties may be assigned.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, protected veteran status or status as an individual with a disability *LI-AH1
EOE/Minority/Female/Disabled/Veteran
