Plan Performance & Quality Reviewer

Blue Cross & Blue Shield of Mississippi; Flowood (MS); On-site; USD 45,000 - 60,000; Full time

Job summary

Blue Cross & Blue Shield of Mississippi is seeking a Plan Performance and Quality Reviewer to assess internal controls and ensure quality outcomes across claims adjudication, membership, and customer service. The role includes evaluating processes, coordinating MTM and PIP audits, and reporting performance improvements.

The ideal candidate will have a Bachelor’s degree or one year of claims processing experience, be proficient in Word and Excel, and demonstrate strong documentation,

Qualifications

• Must have a Bachelor’s degree or one year of experience in claims processing or adjustments.
• Must be proficient in Microsoft Office Suite to include Word and Excel.
• Strong documentation and verbal communication skills are required.
• Must be process and detail oriented to work with a high degree of accuracy and attention to detail to ensure work products are of high quality.
• Must have excellent organizational skills in order to successfully prioritize tasks and perform to ensure individual benchmarks are consistently met.
• Must demonstrate a logical thought process in order to analyze problems and identify solutions.

Responsibilities

• Evaluate the adequacy and effectiveness of internal and operational controls to ensure quality outcomes.
• Perform quality review of departmental functions including claims adjudication, membership, and customer service.
• Identify performance opportunities and report outcomes while ensuring high quality service to customers.
• Coordinate Plan audits related to Member Touchpoint Measure (MTM) and Plan Performance Incentive (PIP) ensuring points are fully met by the Plan.

Skills

Attention to detail

Organizational skills

Verbal communication

Analytical thinking

Documentation

Education

Bachelor's degree

Tools

Microsoft Word

Microsoft Excel

Job description

Healthy Careers Start Here

The Plan Performance and Quality Reviewer is responsible for evaluating the adequacy and effectiveness of internal and operational controls designed to ensure processes and practices lead to quality outcomes. This position will perform quality review of departmental functions including but not limited to claims adjudication, membership, and customer service. This position will be responsible for identifying performance opportunities and reporting outcomes while ensuring high quality service to our customers. The incumbent will also be responsible for the coordination of Plan audits related to Member Touchpoint Measure (MTM) and Plan Performance Incentive (PIP) ensuring points are fully met by the Plan.

Job-Specific Requirements

• Must have a Bachelor’s degree or one year of experience in claims processing or adjustments


• Must be proficient in Microsoft Office Suite to include Word and Excel.


• Strong documentation and verbal communication skills are required


• Must be process and detail oriented to work with a high degree of accuracy and attention to detail to ensure work products are of high quality.


• Must have excellent organizational skills in order to successfully prioritize tasks and perform to ensure individual benchmarks are consistently met.


• Must demonstrate a logical thought process in order to analyze problems and identify solutions.

Blue Cross & Blue Shield of Mississippi is an Equal opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We offer a comprehensive benefits package that is worth approximately one-third of the salary compensation. Our benefits program is among the best in the health care field. We are looking for employees who can bring their experience, expertise and dedication to work for our customers.