Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.<br><br>At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:<br><br><ul><li>Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week</li><li>Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week</li><li>Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month</li><li>Onsite: daily onsite requirement based on the essential functions of the job</li><li>Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building<br><br></li></ul>Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.<br><br><strong>PURPOSE OF THE JOB <br><br></strong>Under direction, performs accurate and detailed audits verifying the accuracy of processing for claims and applications, customer service, and first-call resolution to comply with Blue Cross Blue Shield Association quality control requirements for (MTM and FEP), along with other internal quality control initiatives at Blue Cross Blue Shield of Arizona.<br><br><strong>Required Qualifications<br><br></strong><strong>Required Work Experience</strong> (Applies to All Levels)<br><br><ul><li>2 years of experience auditing, processing claims, processing enrollment transactions, and/or handling customer service calls and/or claim requests</li><li>1 year of basic accounting skills<br><br></li></ul><strong>Required Education<br><br></strong><ul><li>High-School Diploma or GED in general field of study (Applies to All Levels)<br><br></li></ul><strong>Required Licenses<br><br></strong><ul><li>N/A<br><br></li></ul><strong>R<br><br></strong><strong>equired Certifications<br><br></strong><ul><li>N/A<br><br></li></ul><strong>Preferred Qualifications<br><br></strong><strong>Preferred Work Experience </strong>(Applies to All Levels)<br><br><ul><li>3 years of claims, customer service, and enrollment experience</li><li>2 years of experience with auditing and basic accounting skills<br><br></li></ul><strong>Preferred Education<br><br></strong><ul><li>Bachelor's Degree in Business or Healthcare field of study. (Applies to All Levels)<br><br></li></ul><strong>Preferred Licenses<br><br></strong><ul><li>N/A<br><br></li></ul><strong>Preferred Certifications<br><br></strong><ul><li>N/A<br><br></li></ul><strong>Essential Job Functions And Responsibilities<br><br></strong><strong>Level 1<br><br></strong><ul><li>Perform post payment auditing for a variety of contracts/claims, including Local lines of business, BlueCard, FEP, and McKesson.</li><li>Perform audits of member applications, ID cards, and enrollment transactions.</li><li>Perform audits of data in computer files that interface with the claims system in the adjudication of a claim; including enrollment files, pricing files, provider files/contracts, benefit narratives and precertification files, etc.</li><li>Review the accuracy of claims, enrollment files and benefit programming.</li><li>Prepare and maintain documentation supporting the results of audits performed. </li><li>Report audit findings to QC Manager for approval</li><li>Verify the accuracy of cost adjustors on facility claims</li><li>Review claims payment information to support the contract rescission process.</li><li>Review accuracy of pending Local, FEP and BC Host claim payments to Providers over $70,000</li><li>Review and audit complex claims, payments, and applications.</li><li>Ensure claims accuracy from other BlueCross and BlueShield Plans from a Host perspective<br><br></li></ul><strong>Level 2<br><br></strong><ul><li>Can perform all job functions of a Level 1 auditor</li><li>Perform Phone Call, self-service web, IVR, BlueExchange, EDI and other specialized audits for MTM, FEP, groups-specific audits, and targeted audits.</li><li>Assist team in meeting project deadlines and schedules and provide answers and guidance to audit questions.</li><li>Work closely with other departments resolving questions or discrepancies.</li><li>Assist in cross-training Level 1 auditors </li><li>Coordinate and respond to urgent audit inquiries through department proxy boxes.<br><br></li></ul><strong>Level 3<br><br></strong><ul><li>Can perform all job functions of a Level 2 auditor</li><li>Review/audit claims related to manual checks</li><li>Audit claims, inquiries, and enrollment related to Medicare Advantage</li><li>Audit pending high-dollar member-pay claims over $7,000</li><li>Initiate LOA’s for pending high-dollar claims paying to subscriber over $7,000</li><li>Answer questions without Supervisor input/intervention.</li><li>Complete LDLA audits.</li><li>Perform specialized audits, including on-site audits and external audits</li><li>Research cause and effect of errors and work with personnel in all departments to resolve issues.</li><li>Cross-train Levels 1-2 auditors<br><br></li></ul><strong>Level 4<br><br></strong><ul><li>Can perform all job functions of a Level 3 auditor</li><li>Extensive knowledge of FEP and MTM manuals</li><li>Identify trends and gaps in audit findings</li><li>Can perform non-biased audits on QC auditor’s work</li><li>Serve as backup for peer review of quarterly FEP reporting and semi-annual MTM reporting.</li><li>Assist with coaching and development of staff, including the cross-training of Levels 1-3 auditors and auditor questions</li><li>Can batch workload appropriately and manage workload according to internal and external deadlines</li><li>Reconcile completed work with reports, financials, and findings for management and Reporting Analyst<br><br></li></ul><strong>ALL LEVELS <br><br></strong><ul><li>Each progressive level includes the ability to perform the essential functions of any lower levels and assist / mentor employees in those levels.</li><li>The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.</li><li>Perform all other duties as assigned.<br><br></li></ul><strong>Required Competencies<br><br></strong><strong>Required Job Skills</strong> (Applies to All Levels)<br><br><ul><li>Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones</li><li>Intermediate PC proficiency</li><li>Intermediate proficiency in spreadsheet, database and word processing software</li><li>Requires the ability to work with a variety of systems, including, but not limited to, MetaVance, TPS, FEPDirect, ITS, PlanConnexion, Blue 2, Image Retriever, Insurix, TI Portal, Tealeaf, Document Center, and VAT.<br><br></li></ul><strong>Required Professional Competencies</strong> (Applies to All Levels)<br><br><ul><li>Analytical skills to support independent and effective decisions</li><li>Prioritize tasks and work with multiple priorities, sometimes under limited time constraints.</li><li>Perserverance in the face of resistance or setbacks.</li><li>Effective interpersonal skills and ability to maintain positive working relationship with others. </li><li>Verbal and written communication skills and the ability to interact professionally with a diverse group, executives, managers, and subject matter experts.</li><li>Ability to interpret system applications and understand current processing, system, and benefit configurations and changes</li><li>Working knowledge of HIPAA and privacy requirements</li><li>Maintain confidentiality and privacy </li><li>Analytical knowledge necessary to generate reports based on available data and then make decisions based on reported data<br><br></li></ul><strong>Required Leadership Experience And Competencies (Applies To All Levels)<br><br></strong><ul><li>N/A<br><br></li></ul><strong>Preferred Competencies<br><br></strong><strong>Preferred Job Skills</strong> (Applies to All Levels)<br><br><ul><li>Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones</li><li>Advanced PC proficiency</li><li>Advanced proficiency in spreadsheet, database and word processing software<br><br></li></ul><strong>Preferred Professional Competencies (Applies To All Levels)<br><br></strong><ul><li>Identify solutions to meet customer needs</li><li>Work with ambiguous and conflicting information while keeping focused on the end goal.<br><br></li></ul><strong>Preferred Leadership Experience And Competencies (Applies To All Levels)<br><br></strong><ul><li>N/A<br><br></li></ul><strong>Our Commitment<br><br></strong>AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.<br><br>Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
