Audit Specialist

Blue Cross Blue Shield of Michigan•Detroit, MI

12h

About The Position

Update and maintain accuracy of the membership database. This includes but not limited to: processing enrollment files, analytical and statistical error reports, electronic work queues, membership applications and batches for non-group products and Medigap. Responsible for reviewing, processing and maintaining membership eligibility audits (Medicare, Medigap, ESRD, Public Act 275, COBRA, Medicare Crossover Audits, and member level audits for non-group products). Coordinate, monitor, and implement changes in accordance with underwriting guidelines for ACA, TEFRA, COBRA and Medicare. Investigate, research, and resolve discrepancies found in all audits. Coordinate, monitor, and provide liaison activities internally and externally for resolution of Medicare primary/ secondary payer status and Medicaid. Investigate and resolve monthly inquiries from Claims and other departments regarding Medicare. Coordinate discrepancies with CMS (member and group level). Coordinate discrepancies with BPCT and MDCH. Generate and distribute membership reports to applicable departments (i.e., Medicare Status Report, etc) Other duties as assigned by leadership. Work on committees & lead as appropriate. Assist leadership in resolving non-Group eligibility and Medicare questions, and communicate resolutions externally and internally as appropriate.

Requirements

High School graduate or GED required.
Two (2) years of membership processing required.
Intermediate knowledge of underwriting guidelines required.
Extensive knowledge of BCN membership processing systems required.
Possess excellent verbal, written, organizational and problem solving skills.
Ability to manage multiple priorities.
Ability to establish and maintain good working relationships at all levels.
Data entry requirement of 90NKPM with 90% accuracy required
Basic knowledge of Microsoft Word and Excel required.

Nice To Haves

Associates Degree or two (2) years of full time college credits in a Business related discipline preferred.
Knowledge of current Federal regulations such as ACA, COBRA, TEFRA, Medicare, Medicaid etc preferred.
Report writing and preparation skills preferred.

Responsibilities

Update and maintain accuracy of the membership database.
Process enrollment files, analytical and statistical error reports, electronic work queues, membership applications and batches for non-group products and Medigap.
Review, process and maintain membership eligibility audits (Medicare, Medigap, ESRD, Public Act 275, COBRA, Medicare Crossover Audits, and member level audits for non-group products).
Coordinate, monitor, and implement changes in accordance with underwriting guidelines for ACA, TEFRA, COBRA and Medicare.
Investigate, research, and resolve discrepancies found in all audits.
Coordinate, monitor, and provide liaison activities internally and externally for resolution of Medicare primary/ secondary payer status and Medicaid.
Investigate and resolve monthly inquiries from Claims and other departments regarding Medicare.
Coordinate discrepancies with CMS (member and group level).
Coordinate discrepancies with BPCT and MDCH.
Generate and distribute membership reports to applicable departments (i.e., Medicare Status Report, etc)
Other duties as assigned by leadership.
Work on committees & lead as appropriate.
Assist leadership in resolving non-Group eligibility and Medicare questions, and communicate resolutions externally and internally as appropriate.