This position is responsible for the audit functions related to determining and validating FEP Plan performance, as it relates to Membership, Claims and Customer Service activity. The position also provides analysis and feedback as it relates to assigned Performance Guarantee Accounts and participates in external Client audit requests.

• Audits FEP claims, customer service inquiries, member and group enrollment activities in accordance with Plan Incentive Program (PIP) guidelines.
• Completing Performance Guarantee audits.
• Supports IA and SIU with assistance as needed.
• Utilizing internal formatting, maintains adequate documentation to support all audit reviews and outcomes. Providing this material to the appropriate Performance Analyst for internal and BCBSA report compilation.
• Participate in team collaborative efforts to resolve audit issues.
• Utilizes the internal SharePoint Audit tool to communicate findings and follow up assuring corrective action is taken and documented.

Skills:

• Research, analytical and problem-solving skills.
• Mathematical skills required.
• Ability to communicate effectively with diverse audiences both in writing and verbally.
• Ability to address workload to meet numerous deadlines, accommodate and adapt to changing priorities.

Knowledge:

• Understanding of the healthcare industry as it relates to BCBSA.
• Understanding of claims coding and processing including BlueCard, ITS and FEP; membership processes at both the group and member level; and customer service processes, also including FEP.
• Knowledge of FEP benefit products and processing guidelines.
• Knowledge of Facets.
• Familiar with FEPDirect and Microsoft Office applications especially Excel.

Experience:

• A minimum of 5 years' experience in Claims, Membership or Customer Service (or combination of the three); depending on current business needs.
• Knowledge of FEP required.
• Audit and/or analytical experience required.

Education and Certifications:

• High School diploma or GED.

Work Environment:

• Fully Remote.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must be able to work over 40 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds. Must be able to work in excess of 37.50 hours a week when necessary.

 

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.