This position is responsible for the audit functions related to determining and validating Plan performance, as it relates to Membership, Claims and Customer Service activity. This is accomplished through accordance with established policies, internal procedures and BCBSA mandated audit guidelines related to the following compliance programs LOS, FEP, LDLA and OPM-MSP. The position also provides analysis, reports and feedback as it relates to assigned Performance Guarantee Accounts and participates in external Client audit requests.

• Audits claims, customer service inquiries, member and group enrollment activities, product builds as well as focus and client audits as assigned. 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.
• Completes the BCBSA LDLA Tool with the required information during LDLA reviews and provides completed work to the Reviewer for required review. Utilizes Reviewer feedback to assure independent compliance with the Program, identifying trends and assure ongoing accuracy.

Skills:

• Research, analytical and problem-solving skills.
• 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 Capital
• Understanding of claims coding and processing including BlueCard and FEP; membership processes at both the group and member level; and customer service processes, also including FEP.
• Familiar with Capital’s various product designs and their coding structures.
• Familiar with Facets and FEPDirect
• Familiar with 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 desired.
• Audit and/or Analytical experience desired.

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.