Quality Auditor I-1

Horizon Blue Cross Blue Shield of New Jersey•Newark, NJ

About The Position

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. The role is responsible for ensuring service operations compliance with product guidelines and conducting audits.

Requirements

High School Diploma/GED required.
Minimum of two (2) of quality or audit or training experience
Requires expert level knowledge of multiple lines of claim processing systems and business
Ability to interface with all levels of personnel, and external clientele
Organization
Multitasking
Analytical Thinking
Strong Interpersonal Presentation Skills

Nice To Haves

Minimum of three (3) years with a strong knowledge of processing experience preferred
Position may require bilingual skills (i.e. Spanish) for pre-determined lines of business / vendor partners.

Responsibilities

Performs statistically valid audits based on the BCBSA or Performance Guarantee, and other Horizon guidelines to determine the accuracy of responses to inquiries.
May conduct trending: identifying top errors and improvements, identifying strengths, escalating areas of improvement and tracking best practices.
Assist in maintaining keying guidelines and disseminate quality alerts used by vendor(s).
Will assist in appeals process with multiple business partners by providing supporting information.
Will act as coach for vendor samples and performance training.
Documents identified defects to develop root cause and provide recommendations for process improvements or system enhancements for the overall improvement of accuracy efficiencies
Maintains records of all source documentation reviewed. This includes but is not limited to electronic raw data, provider contracts, pricing information, and benefits.
Provides support to operations staff.
May use educational tools to address to improve overall accuracy.
Review benefits against the original source document for validation.
Conducts Focused Audits in support of management, customer, and Internal Audit department requests and provides feedback to reduce errors and improve processes and performance.
May support enterprise wide projects by understanding the scope of the project, ensure timely and accurate project completion, will report findings to the appropriate personnel.
Participate in regular internal /external meetings for purposes of calibrations, trends, best practice sharing, identify process improvements, and streamline processes.
May be responsible for first draft review of audit points for focused audits such as PG and MTM.
Perform other related tasks as assigned by management.