Quality Specialist
Job Summary
Responsibility for completing accuracy reviews of case samples for program audits. Assesses operational and service performance of substantially all branded, core health business. The most common branded health lines of business included in the Program are: HMO, PPO, Indemnity, Traditional, Medicare Advantage, Medicare Supplemental products, Medicare Replacement products, and Medicaid. This includes ASO functions performed by the Plan. All services administered by the Plans that cover enrollment, claims and customer service must be measured and reported in accordance with the BCBSA Program Guides.
Responsibilities
1.Review transactions to ensure completeness and accuracy by using information available within the Plan for monthly case samples. Case reviews are done back to source documents which includes but is not limited to:
- Signed/Acknowledged group/member benefit contracts as well as at time the Sales Approved group benefit Product Configurator System
- Provider contracts for facility and professional services with review of specific detail on pricing requirements within the contracts (reading and assessing information within the contracts as defined by the various BCBSA Guide requirements)
- Pricing fee schedules for providers along with calculations for specific defined pricing polices for varying types of services, assessment for pricing detail is from sources in the plan prior to any upload to the processing system
- Understanding and reading data files (i.e., HIPAA 837/834) from groups and providers for member and claim details to assess the processing systems are accurately reflecting the details submitted
- Provider data demographics from provider credential documents, provider portals, letters, phone calls to providers or other sources in the provider network business area
2.Auditing against the methods and requirements as deemed compliant by the various BCBSA Program Audit Guides.
3.Creating audit packet documents as our plan’s internal source for evidence of what was reviewed during the sample case assessment. Packets include screen shots of all source documentation assessed at the time of the case review and any pertinent IBC policy provisions that are part of the case determination as defined in the program requirement guides
4.Monitor deadlines and serve as a technical liaison when appropriate for sample transaction questions
5.Assess regulations for compliance of audit reviews per program audit guidelines, required data sources and incorporate what is required into the specifications and/or documentation
6.Identifies trends related to findings, reports audit outcomes as needed to related business units, and support or implements enhancements based on results with appropriate personnel
7. Tracks pended case issues and makes recommendations for improvements
8.Communicate effectively in writing and verbally with in work groups and internal and external customers
9.Attend internal and external education training to achieve and maintain proficiency on all systems
10.Meet required audit deadlines and quality standards
Education
Auditing practices and methodologies
Knowledge, Skills, Abilities
Knowledge of systems related to Claims adjudication or Enrollment practices or Inquiry transactions for processing practices, and timelines to ensure handling of cases comply across operational disciplines.
Ability to compile detailed documentation, and data mining to support audit requirements. Skilled in trend analysis and effective in communicating as the liaison with business partners on findings and recommendations focused on minimizing impacts to other areas and the customer.
Strong written and verbal communication skills are required as well as attention to detail when reviewing transactions.
Maintain flexibility in a team environment, escalate findings to management and identify process improvement opportunities and trending.
Diversity, Equity, and Inclusion
At AmeriHealth, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
About Our Company
Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.
At AmeriHealth, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!
Equal Employment Opportunity
AmeriHealth is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Agency Disclaimer
All resumes submitted directly to an AmeriHealth employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of AmeriHealth and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by AmeriHealth or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.