Internal QC Call Auditor I-II Medicare Advantage
Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering 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.
Purpose of the Job
Under direction, performs accurate and detailed audits verifying the accuracy of call logged into the call tracking system. Provides various types of reporting. Coordinates management reviews of staff performance metrics and associated corrective action plans when necessary.
Essential Job Functions & Responsibilities
• Conduct 100% of daily calls for the internal member service team.
• Perform audit of call categorization.
• Perform audits of calls to ensure appeals, grievances, and organization determinations were submitted.
• Prepare and maintain documentation supporting the results of audits performed.
• Report audit findings to manager.
• Complete daily and monthly audit reports.
• Provide regular performance feedback to participants and management.
• Suggest revisions to existing training materials.
• Recommend training needs based on audit trends.
• Provide feedback to the Managers regarding errors, referencing appropriate policy or procedure.
• Respond to questions from internal teams regarding audit deficiencies identified.
• Develop and maintain technical documentation on how to conduct audits and distribute to the teams.
• Consult and coordinate with various internal and external departments.
• Respond to audit appeals in an effective, efficient, and timely manner.
• 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.
• Demonstrate/maintain current working knowledge of required BCBSAZ/CMS systems, procedures, forms and manuals.
• Develop working relationships with subject matter experts to ensure current knowledge of systems / changes.
BCBSAZ 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.
Skills / Requirements
1. Required Work Experience
• 3 years of experience in a healthcare production field
2. Required Education
• High-School Diploma or GED in general field of study
3. Required Licenses
4. Required Certifications
1. Preferred Work Experience
• 5 years of experience in a healthcare production field
• 2 years of experience in either training or auditing of production work
2. Preferred Education
• Associate's Degree in Business or Health Care
3. Preferred Licenses
4. Preferred Certifications
1. Required Job Skills (Applies to All Levels)
• Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
• Advanced PC proficiency
• Intermediate proficiency in Micorsoft Office programs
• Requires the ability to work with a variety of systems, including but not limited to Guiding Care, Health Rules Payer (HRP), and Wipro (M360)
2. Required Professional Competencies
• Analytical skills to support independent and effective decisions
• Prioritize tasks and work with multiple priorities, sometimes under limited time constraints.
• Excellent proofreading skills.
• Perserverance in the face of resistance or setbacks.
• Effective interpersonal skills and ability to maintain positive working relationship with others.
• Requires ability to apply corporate and/or contractual guidelines and standards.
• Self motivated and able to work with minimal direction and exercise sound judgment
• Excellent verbal and written communication skills with a focus upon the ability to write and present audit research in the context of corporate and/or contractual guidelines.
• Ability to work closely with Member Service and Delegation Oversight management, IT, and other department personnel within the Corporation and maintain effective and cooperative relationships with all levels of Plan.
• Verbal and written communication skills and the ability to interact professionally with a diverse group, executives, managers, and subject matter experts.
• Ability to interpret applications and understand current processing, system, and benefit configurations and changes
• Working knowledge of HIPAA and privacy requirements
• Maintain confidentiality and privacy
• Analytical knowledge necessary to generate reports based on available data and then make decisions based on reported data
• Maintain confidentiality and privacy
• Intermediate skill/ability to speak professionally to staff and management
• Intermediate skill/ability to use proper written communications to provide appropriate feedback on audits
3. Required Leadership Experience and Competencies
• Facilitate discussion at the group or individual level
• Ability to direct and assist others
1. Preferred Job Skills (Applies to All Levels)
• Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones
• Expert PC proficiency
• Advanced proficiency in spreadsheet, database and word processing software
2. Preferred Professional Competencies (Applies to All Levels)
• Identify solutions to meet customer needs
• Work with ambiguous and conflicting information while keeping focused on the end goal.
3. Preferred Leadership Experience and Competencies (Applies to All Levels)