Manager QA and Reporting

Cambia Health • Pocatello, ID

63d • Hybrid

About The Position

Every day, Cambia's Operations and Compliance Team is living our mission to make health care easier and lives better. The Manager of Quality Assurance And Reporting directs, develops and leads the staff accountable for providing Health Plan Operation Quality Assurance Auditing and Reporting. Accountable for the timely and accurate external corporate reporting for the Blue Cross Blue Shield Association (BCBSA) Local Operations Scorecard (LOS) and Licensee Desk Level Audit (LDLA), as well as Performance Guarantee performance measures. Responsible for the interpretation of LOS, LDLA, and PG policies and regulations and for the implementation of the necessary statistically valid audit procedures to assess these performance measures. May also be responsible for internal high dollar prepay, staff performance auditing activities, external audit support, or compliance audits. Responsible for writing audit programs, evaluating audit results, and reporting to internal Senior Management any quality issues and areas where quality improvement is needed. Primary business contacts include BlueCross BlueShield Association, affiliate Plan LOS or LDLA peers, Member and Provider Experience, Claims, Group and Member Administration, DTS, and Provider Services Division management - all in service of making our members' health journeys easier. If you're a motivated and experienced QA & Reporting Leader looking to make a difference in the healthcare industry, apply for this exciting opportunity today!

Requirements

• Bachelor's degree in Business, Accounting, Health Care, Management or related field
• minimum three years experience in a leadership or supervisory position
• Equivalent combination of education and experience
• Ability to communicate effectively, verbally and in writing with all levels of Cambia personnel.
• Ability to lead and participate in a team environment to achieve department goals and objectives consistent with corporate vision and strategies.
• Ability to interpret regulations and external reporting requirements, plan for and successfully implement changes in LOS, LDLA, performance guarantee, and staff performance audit requirements, including appropriate sampling methodology, audit oversight, and concise and accurate reporting.
• Knowledge of audit techniques and statistical sampling methods and procedures including sample sizes, variances, confidence levels, random and stratified sampling, and precision levels.
• Knowledge of generally accepted auditing procedures and practices, obtained through an auditing course or prior work experience.
• Knowledge of quality tools and quality improvement methodologies.
• Demonstrated effective and diplomatic interpersonal skills with all levels of staff and management
• Demonstrated analytical ability in identifying problems, developing solutions and implementing effective courses of action.
• Ability to think clearly under pressure and project a professional image at all times.
• Strong proficiency with personal computer applications including Microsoft Excel, Word, and PowerPoint.

Nice To Haves

• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired
• Five years of experience in claims, membership, or customer service activities is desired

Responsibilities

• Responsible for developing and implementing quality audits throughout Health Plan Operations to ensure that quality service levels are met or exceeded.
• Prepares and maintains reference manuals and audit programs/procedure guidelines for all Quality Assurance audits and reports.
• Maintains knowledge of the BlueCross and Blue Shield Association LOS Program, LDLA, and Performance Guarantee Audit measures, standards and reporting procedures.
• Analyze and report audit results using graphs/trending in order to highlight and prioritize quality improvement opportunities.
• Identify error trends and work with business areas to reduce repeat errors.
• Lead cross-functional quality improvement initiatives by collaborating with Claims, GMA, and Member and Provider Experience, and other divisions to implement corrective action plans.
• Contribute to and/or manage Quality Assurance Audit & Reporting corporate initiatives.
• Prepare requests for new or changes to existing audit sampling methods and procedures. Tests sampling program changes and directs implementation.
• Assists with the preparation of the annual budget for the department and monitors monthly operating expenses to ensure they are within budget.
• Facilitate regular quality review meetings with cross-functional teams to discuss findings, share best practices, and coordinate improvement initiatives.
• Demonstrate analytical ability in identifying problems, developing solutions and implementing an effective course of action.
• Help drive the resolution and completion of outstanding Corrective Action Forms (CAF) that involve repeat audit findings.
• Ensure hiring, performance evaluations, training and employee development promotes improved production and efficiency along with employee satisfaction.
• Give presentations to staff or management of various departments in such a way as to promote understanding and motivation to improve or maintain corporate performance levels.
• Direct and evaluate the activities of subordinates to assure work is completed in an effective accurate and timely manner.
• Responsible for hiring, performance evaluations, training and employee development.
• Optimize audit processes by leveraging technology where possible.
• Integrate audit findings into the training and documentation programs to drive continuous improvement.

Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Industry: Ambulatory Health Care Services
• Number of Employees: 5,001-10,000 employees