Quality Assurance Officers

Premera Blue Cross; Sioux Falls (SD); On-site; USD 50,000 - 70,000; Full time

Benefits offered by this job

Health insurance

Retirement plan

On-site parking

Wellness center

Job summary

Premera Blue Cross in Sioux Falls, SD is seeking an Enrollment Oversight and Quality Specialist to handle enrollment, eligibility, billing changes and audits with strong customer service. You will support internal and external customers via phone, email or written correspondence, explaining guidelines and offering alternatives as needed.

The role includes participating in late shifts, cross-functional collaboration, and maintaining training materials to improve efficiency and accuracy in

Qualifications

• High School diploma or GED required; 2 years of accounting/finance/bookkeeping or enrollment processing experience preferred.
• Experience in health or insurance enrollment, eligibility, billing and reconciliation processes.
• Strong customer service skills and ability to explain administrative guidelines clearly.

Responsibilities

• Perform enrollment, eligibility, billing changes and reconciliation tasks.
• Research and resolve complex enrollment and billing issues for members and agents.
• Conduct audits and implement process improvements in collaboration with partners.
• Educate agents and members on membership and billing rules and portal usage.
• Support strategic partners with training material and performance tracking.
• Complete special projects and ensure timely action on audit findings.

Skills

Customer service

Enrollment processing

Billing and reconciliation

Complex systems

Education

High School diploma or GED

Tools

Web portal usage

Regulation interpretation

Job description

Our purpose, to improve customers' lives by making healthcare work better, is far from ordinary. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

By investing in our employees and fostering a culture of collaboration and continuous development, we're able to better serve our customers. Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog:

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The

Enrollment Oversight and Quality Specialist

will perform moderate to complex enrollment, eligibility, billing changes and reconciliation, and account research using a variety of methods, systems and platforms. This role is expected to have exceptional customer service skills and interact with internal and external customers in a timely and professional manner via phone, email or written correspondence within established department turnaround times. Must be able to thoroughly explain administrative and regulatory guidelines, their impact and offer alternatives to our members/agents. This role will include the development, maintenance and tracking of related audits, procedures, and efficiency work in team and as it relates to our strategic implementation partners.

Candidates must be available to support business operations during the department's 7:00 AM to 5:00 PM PT coverage window. This role also requires participation in a late-shift rotation, typically one day per week, with occasional additional coverage based on business needs. Late-shift hours are 8:30 AM to 5:00 PM PT.

Provides technical support to assigned teams/strategic implementation partners by researching and/or troubleshooting issues related to processing, system, and software applications.

• Serves as a resource for customers by researching complex systems issues impacting member eligibility and determining appropriate course of action. Conduct performance audits to ensure transaction compliance, accuracy and timeliness. Identifies, recommends and implements process improvements.
• Represents department on cross-functional teams and meets with external customers as required.
• Regularly reviews procedures and training material for in-team and strategic implementation partner training, through partnership with the training and quality coaching teams, to outline and implement improvements for increased efficiency.
• complete special projects and perform other duties as assigned.
• Tracks, monitors, updates, and follows-up with strategic implementation partner on audit findings, action plans, and information requests to ensure each item on the action plan is completed in a timely and accurate manner.
• Update eligibility, enrollment and/or billing of accounts.
• Contact customers or Producer agents for enrollment clarification and/or to provide administrative/regulatory guidelines. This may include creating written correspondence regarding complex billing and enrollment issues.
• Must meet or exceed department production and quality standards and remain current on company/departmental policies and procedures.
• Educate agents and members on general membership and billing processes and administrative rules; may include Web portal usage and contract or regulation interpretation.

High School diploma or GED. (Minimum of two (2) years of accounting/finance/bookkeeping experience or two (2) years enrollment processing experience. (Previous customer service experience. (Health or insurance industry experience. (Expertise in complex enrollment, eligibility, billing, and reconciliation processes

Experience conducting audits and improving quality and efficiency

Increased knowledge of healthcare regulations and administrative guidelines

Collaboration experience with customers, partners, and cross-functional teams

The following have been identified as essential physical requirements of this job and must be performed with or without an accommodation:

• This role requires the ability to use a keyboard and to communicate clearly and understandably in person and over the telephone.

Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:

• Medical, vision, and dental coverage with low employee premiums.
• Life and disability insurance.
• Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service.
• We have tuition assistance for both undergraduate and graduate degrees.
• For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.
• Free convenient on-site parking.
• Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
• Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
• Challenge someone to a game of shuffleboard or ping pong while on campus.

Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at or via phone at.

we generally target up to and around the midpoint of the range.