This position is responsible for auditing samples of claims, status inquiries or subscriber membership changes for at least one line of business in order to determine if they were processed correctly according to MTM, BCBSM, BCN or account guidelines. For all identified errors, notifies responsible departments and conducts follow-up to verify correction.
Review and analyze written and telephone claims, inquires, and enrollment transactions to verify they were processed accurately and completely.
Document review results and assist Audit Analyst in the development of error trend analyses.
Monitor telephone calls and notify operational areas of all identified errors and rationale for assigning errors.
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.
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).
Complete 40 hours of continuing education annually.
Other duties may be assigned.
" Qualifications"
High School Graduate or GED equivalent required working towards college degree preferred.
Three (3) years BCBSM or BCN experience in at least four (4) lines of core business, related systems and processes (e.g., claims, membership, inquiries, medical policy, benefit policy, pricing, etc.).
Must be proficient in the examination of at least three (3) lines of business for claims, inquiries or enrollment processing.
Ability to work with minimal direction.
Communication skills necessary in order to be able to interact with operational managers (including directors) regarding errors, clarifications, and calibrations.
Strong analytical skills required in order to determine the type of errors.
Excellent problem solving skills and time management skills.
High level of proficiency in use of basic technology and BCBS processing systems (PRISM, NASCO, and the inquiry control system) Microsoft Word and Outlook, Interactive Voice Response Units, and web browsers (i.e Internet Explorer) and ASPECT phones.
Ability to work with minimal direction.
Other related skills and/or abilities may be required to perform this job.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
Equal Opportunity Employer–minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity
Please see job description for required skills.
