Analyst Claims - Claims Audit and Quality

Blue Cross Blue Shield of Michigan • Detroit, MI

23h

About The Position

Responsible for analyzing, reconciling, and reporting quality-team activities and audit results for individuals and the department. Uses data to identify trends and root causes of problems and participates in cross-functional efforts with staff and leaders to address them. Works with BCBSM quality assurance staff to validate or dispute MTM findings and report findings to the corporation.

Requirements

• Two years of college in a business- or health-care-related field.
• Three years of operational experience in a health care setting, including two years of claims processing or inquiry resolution experience with the Facets system.
• Experience working effectively in a team environment.
• Excellent problem-solving skills, including the ability to analyze, identify, and communicate recommendations regarding quality trends and process-improvement opportunities.
• Prioritization, organizational, and self-motivation skills to work independently on multiple tasks and changing priorities within expected timeframes.
• Excellent written and verbal communication skills to communicate complex or technical information effectively.
• Excellent interpersonal skills, including the ability to interact with all levels of external and internal customers.
• Demonstrated knowledge of Microsoft Office Suite and related PC software.
• Other related skills and/or abilities may be required to perform the job.

Nice To Haves

• Experience in the BCN Claims Quality area.
• Experience documenting issues, processes, and workflows.
• MA PPO claims experience.
• NASCO experience.

Responsibilities

• Compile, analyze, and calculate accuracy scores for individual, team training, MTM, high-dollar, and high-error-rate reports.
• Create and research detail for root-cause analysis and trends.
• Administer the MTM process, including disputes.
• Audit quality-team review staff.
• Handle first-level appeals from claims staff regarding quality findings and error assignments.
• Act as a liaison between the quality team and partner departments to address issues, including ensuring adjustments identified through quality audits are completed; reviewing new or modified procedures for accuracy with Document Training Specialists; and working with claims process improvement staff and leadership to respond to or monitor audit activity for internal and external reviews and audits.
• Gather, analyze, and report trends in quality results and work with leaders and other staff areas to correct underlying causes of errors.
• Complete special projects as assigned.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree