Plan Performance & Quality Reviewer

Blue Cross & Blue Shield of Mississippi•Flowood, MS

About The Position

The Plan Performance and Quality Reviewer is responsible for evaluating the adequacy and effectiveness of internal and operational controls designed to ensure processes and practices lead to quality outcomes. This position will perform quality review of departmental functions including but not limited to claims adjudication, membership, and customer service. This position will be responsible for identifying performance opportunities and reporting outcomes while ensuring high quality service to our customers. The incumbent will also be responsible for the coordination of Plan audits related to Member Touchpoint Measure (MTM) and Plan Performance Incentive (PIP) ensuring points are fully met by the Plan.

Requirements

Bachelor’s degree or one year of experience in claims processing or adjustments
Proficient in Microsoft Office Suite to include Word and Excel.
Strong documentation and verbal communication skills
Process and detail oriented to work with a high degree of accuracy and attention to detail to ensure work products are of high quality.
Excellent organizational skills in order to successfully prioritize tasks and perform to ensure individual benchmarks are consistently met.
Demonstrate a logical thought process in order to analyze problems and identify solutions.

Responsibilities

Evaluating the adequacy and effectiveness of internal and operational controls designed to ensure processes and practices lead to quality outcomes.
Performing quality review of departmental functions including but not limited to claims adjudication, membership, and customer service.
Identifying performance opportunities and reporting outcomes while ensuring high quality service to our customers.
Coordinating Plan audits related to Member Touchpoint Measure (MTM) and Plan Performance Incentive (PIP) ensuring points are fully met by the Plan.