Claims Quality Assurance (Remote - AZ)

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:

• Hybrid People Leaders: must reside in AZ, required to be onsite at least once per week

• Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month

• Onsite: daily onsite requirement based on the essential functions of the job

• Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per month.

PURPOSE OF THE JOB

This position audits all claims for proper adjudication while handling special projects, reopens, refunds and void processes. The auditor will maintain proper record keeping of all support files and be responsible for providing in-service to appropriate personnel with regard to changes and updates in claims processing guidelines. This position is heavily based on quality and audit related tasks however inventory work may be assigned based on business needs.

This remote work opportunity requires residency, and work to be performed, within the State of Arizona. 

QUALIFICATIONS

REQUIRED QUALIFICATIONS

• Required Work Experience
  • 3 years of experience in claims adjudication in an automated environment
• Required Education
  • High-School Diploma or GED in general field of study 
• Required Licenses
  • N/A
• Required Certifications
  • N/A

PREFERRED QUALIFICATIONS

• Preferred Work Experience
  • 5 years claims auditing experience
• Preferred Education
  • Associates Degree in general field of study
• Preferred Licenses
  • N/A
• Preferred Certifications
  • N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Audits claims for accuracy of the data, payments, contract interpretation and compliance within established policies and procedures.
• Selects claims through random and targeted process to conduct audits to ensure compliance standards are met.
• Manages the claims administration workflow in a timely and accurate manner necessary to meet
• Plan requirements associated with the Plan’s benefit process, policies and procedures
• Acts as the primary claims resolution specialist for internal and external clients related to escalated claims issues and for claims adjudication and handling of difficult claims issues.
• Provides information to providers/members and maintains system information as necessary for internal and external auditing purposes.
• Develops and creates reports necessary to track and monitor workflow efficiencies.
• Makes training recommendations and submits regularly to claims supervisor or manager.
• Leads team and one-on-one training sessions as directed by management. Gathers documents requested for all internal and external audits.
• The position requires a full-time work schedule.  Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned.

COMPETENCIES

REQUIRED COMPETENCIES

Required Job Skills

• Claims processing, including UB, 1500 and dental 
• Medical terminology 
• CPT/HCPC and ICD10 coding 
• Experience with multi-tasking and prioritizing 
• Type 30 to 35 words per minute with 5% error rate or less 
• Intermediate PC proficiency 
• Strong oral and written communication skills 
• Proficient spelling, punctuation and grammar skills 

Required Professional Competencies

• Maintain confidentiality and privacy 
• Compose and dictate a variety of business correspondence 
• Interpret and translate policies, procedures, programs and guidelines 
• Capable of investigative and analytical research 
• Navigate, gather, input and maintain data records in multiple system applications 
• Follow and accept instruction and direction 
• Establish and maintain working relationships in a collaborative team environment 

Required Leadership Experience and Competencies

• N/A

PREFERRED COMPETENCIES

Preferred Job Skills

• Type >35 words per minute with 5% error rate or less 
• Intermediate knowledge of CPT, HCPCS and ICD9 claim coding 
• Intermediate understanding of dental and medical terminology 
• Intermediate comprehension of anatomy and medical practices 
• Bilingual (Spanish/English) skill in written communication 

Preferred Professional Competencies

• Knowledge of a wide range of subjects pertaining to the organization's service and operations 

Preferred Leadership Experience and Competencies

• N/A

Our Commitment

AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona.  For more information on our company, see azblue.com.  If interested in this position, please apply.