Quality Assurance Specialist II (REMOTE)

Capital Area Services Company, LLC; Charleston (WV); Remote; USD 47,000 - 88,000; Full time

Job summary

A leading company in quality assurance is seeking a Quality Assurance Specialist II to coordinate efforts in Claims audits and improve customer satisfaction. The ideal candidate will have extensive experience in auditing processes and a solid understanding of quality assurance practices. Responsibilities include conducting audits, providing training, and making recommendations for operational improvements.

Qualifications

• 5 years experience in Auditing, Quality Assurance, Operations, or Project Management required.
• Proficient in using various claim processing systems.
• Subject matter expert in auditing practices and providing training to analysts.

Responsibilities

• Coordinate and perform monthly audits of internal operations.
• Submit audit findings to management and provide recommendations for improvement.
• Identify procedural inconsistencies and initiate resolutions.

Skills

Knowledge of quality assurance and production technologies

Proficient in Microsoft Office programs

Knowledge of industry standards and quality control techniques

Excellent communication skills

Excellent research and organizational skills

Strong interpersonal skills

Extensive analytical and problem-solving skills

Education

High School Diploma or GED

Job description

Resp & Qualifications

PURPOSE:
The Quality Assurance Specialist II performs and participates in the coordination and required research of Claims audits received from both OPM and DO. The audits are designed to determine the efficiency and effectiveness of CareFirst internal operations areas to ensure high levels of customer satisfaction.The specialist is responsible for knowing external requirements including BCBSA and Directors Office guidelines, including Performance Measurement Framework performance standards.Coordinates efforts with Quality Assurance Specialist III to complete audits within the scheduled timeframes and supports corporate special audits for root cause and fiduciary/expense avoidance situations. Participates in Root Cause and Frequency analysis to assist in identifying potential areas of risk that may impact both our providers and subscribers and to identify opportunities for improvement to systems and business processes. Provides input and recommendations to improve processes or to update SOPs based on audit findings.

ESSENTIAL FUNCTIONS:
Under the general direction of the Supervisor, the incumbents accountabilities include but are not limited to the following:

• Performs monthly audits of the internal operations area by auditing the claims included in the listings received from External & Internal Auditors, DO and/or OPM/OIG. The validation of the errors and audits may include but are not limited to claims, Audit and Recoupment, Provider retention and carryover in accordance with the guidelines. Reviews all system data as well as payment methodologies to ensure compliance with all contractual obligations as agreed to by the group, subscriber and provider.Ensure that all actions were executed in accordance with CareFirst medical policy on both the local and national levels. To validate the errors and to perform the audits may include using any one of the following listed processing systems but not limited to Direct, TRMS, SIR, Bridge Console, TriZetto Networx Pricer, Portico, Guiding Care, ClaimsXten- total Payment Solution, CXP, CMRP, and CAMT and all related activity performed within this tool. Adjusts incorrectly processed claims and initiates recovery efforts according to local Plan policies. Participates in projects, workgroups, including those from upper CareFirst management (Directors, Vice Presidents, and Senior Vice Presidents) and data base maintenance.
• Serves as a subject matter expert for new analysts, auditing practices; whats to be audited, how to perform the audits, documenting findings, and completing follow-up work on the audits. Provides training to new analysts. Submits audit findings to Operations Management that outline the root cause of identified issues as well as provide recommendations for corrective action, system and procedural modification and enhancements to improve service and quality. Issues may include, but are not limited to: weaknesses, inconsistencies and inaccuracies in procedures, controls and system integrity.
• Identifies procedural inconsistencies, system issues and training opportunities based upon audit findings and initiates resolution to these problems by evaluating the effectiveness of current processes/procedures, techniques, systems and associates and recommending alternate procedures/processes and developing SOPs.
• Perform follow-up activities related to audits/reviews, special projects, and other duties as assigned thus ensuring that corrective actions have been appropriately taken.

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Experience: 5 years Auditing, Quality Assurance, Operations, Training, Project Management or comparable work experience.

Knowledge, Skills and Abilities (KSAs)

• Knowledge of quality assurance and production technologies.
• Proficient in Microsoft Office programs.
• Knowledge of industry standards, quality control techniques and procedures.
• Excellent communication skills both written and verbal.
• Excellent research and organizational skills.
• Strong Interpersonal skills.
• Extensive analytical and problem-solving skills.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $47,664 - $87,384

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Case Management Claims Pro

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of theCompany to provide equal employment opportunities to allqualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship