Job Description

Under the direct supervision plan, organize and monitor audit coordination activities according to departmental priorities. Provide assistance to the primary audit coordination functions in obtaining, analyzing and compiling data for audits of BCBSM by external parties. Perform claim analysis, respond to Par Plan inquiries and other assignments as required to meet corporate, divisional and departmental goals and objectives.

• Plan, organize, direct and monitor audit coordination activities for external audits of small to medium ASC groups consisting of up to 200 claim samples.
• Coordinate Claims Recovery and Voluntary Employee Benefit Association (VEBA) and Control Plan audits; approximately 5 to 25 audits concurrently.
• Review and distribute questions from external auditors to appropriate departments and review the responses to validate their accuracy and completeness.
• Distribute questionnaires from external auditors and assist in compiling a corporate response. External auditor generally conducts off-site desk level reviews.
• Obtain claim documentation for all lines of business and claim systems and calculate claim payments or re-price claims samples.
• Follow-up on corrective actions (generally claim adjustments and recoveries) and report progress of recovery to external auditors and leadership in a timely manner.
• Other duties and responsibilities as may be assigned.

• Bachelor's degree preferred. Health Services Administration, Business Administration, Accounting, Finance or related field are preferred
• Three (3) years in related field of claims processing, customer service, benefit policy interpretation or claims systems.
• Two (2) years BCBSM experience auditing or performing analytical assignments, benefit interpretation and customer service or working with the public preferred.
• Knowledge of NASCO/MOS claims processing, BCN/Facets, MEDCO, Medicare Advantage and BlueCard claims and knowledge of back-end data reporting preferred.
• Basic project management skills.
• Knowledge of generally accepted auditing principles and theories.
• General knowledge of Par Plan and/or Control Plan activities
• Excellent analytical, organizational, planning, verbal and written communication skills.
• Ability to analyze, investigate and organize ideas in recognizing, defining and formulating solutions to problems.
• Excellent interpersonal skills to effectively interface with all levels of BCBSM personnel, external auditors and customers.
• Proficient in current industry standard PC applications and systems (e.g. Word, Excel and Microsoft Office).
• Ability to work independently, within a team environment and handle multiple priorities.
• Other related skills and/or abilities may be required to perform this job.
• Must be able to travel to various BCBSM locations within and outside the state, and BCBSM plans.

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