Plan Performance & Quality Reviewer

Blue Cross & Blue Shield of Mississippi; Mississippi; On-site; USD 45,000 - 65,000; Full time

Job summary

Blue Cross & Blue Shield of Mississippi is seeking a Plan Performance and Quality Reviewer to evaluate the adequacy of internal and operational controls, ensuring quality outcomes. The role conducts quality reviews of claims adjudication, membership, and customer service functions and reports opportunities for performance improvements.

The incumbent coordinates audits related to MTM and PIP to ensure points are met by the Plan and maintains rigorous documentation and communication with

Qualifications

• Bachelor’s degree or one year of experience in claims processing or adjustments.
• Proficient in Microsoft Office Word and Excel.
• Strong documentation and verbal communication skills.
• Detail oriented with high accuracy and quality.

Responsibilities

• Evaluate the adequacy and effectiveness of internal and operational controls.
• Perform quality reviews of claims adjudication, membership, and customer service.
• Coordinate audits related to MTM and PIP and report outcomes.

Skills

MS Office Suite

Documentation & Communication

Attention to detail

Organizational skills

Analytical thinking

Claims processing experience

Education

Bachelor’s degree or one year of experience in claims processing or adjustments

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. At Blue Cross & Blue Shield of Mississippi, we work daily to help Mississippians find their personal answers to this question through health and wellness partnerships with quality healthcare providers, employer groups and community leaders across the state. Our goal is to help each person along their journey to a healthier life… their Blue Wellness Journey.

Our health and wellness benefits are designed to support our members in understanding their health and in receiving the care they need at the right time and place, beginning with establishing a healthy relationship with a Primary Care Network Provider through an annual wellness visit at no out-of-pocket cost.

We partner with our Network Providers to ensure the highest quality, evidence-based care is provided in each care setting from primary care to specialty care through our Primary Care Home, Blue Distinction+ Centers of Excellence and Maternity Care Quality initiatives.

We partner with employer groups to make every workplace a healthy workplace by providing tools and information to help employees take ownership of their health and understand and make the most of their benefits, all while working to manage health and healthcare costs.

We partner with community leaders and organizations to make healthy living resources available to all Mississippians through the work of the Blue Cross & Blue Shield of Mississippi Foundation, our support of the arts and culture and our Team Blue volunteers. These partnerships and our dedicated team of employees are making a difference every day, in our communities and in the lives of each person we reach.

So, what does it mean to be healthy? The answer is about you, your health, your life… and all its possibilities. Live healthy. Live Blue.