Plan Performance & Quality Reviewer

About the role

The Plan Performance and Quality Reviewer evaluates internal and operational controls to ensure processes and practices lead to quality outcomes. This includes reviewing claims adjudication, membership, and customer service functions.

Responsibilities

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

Requirements

• Bachelor’s degree or one year of experience in claims processing or adjustments
• Proficient in Microsoft Office Suite to include Word and Excel
• Strong documentation and verbal communication skills
• Process and detail oriented to work with a high degree of accuracy and attention to detail
• Excellent organizational skills to prioritize tasks and meet individual benchmarks
• Demonstrate a logical thought process to analyze problems and identify solutions

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
• Must have strong documentation and verbal communication skills
• Must be process and detail oriented to work with a high degree of accuracy and attention to detail
• Must have excellent organizational skills to prioritize tasks and meet individual benchmarks
• Must demonstrate a logical thought process to analyze problems and identify solutions

Skills

• Claims processing or adjustments
• Microsoft Office Suite proficiency (Word, Excel)
• Documentation and verbal communication skills
• Process and detail orientation
• Organizational skills
• Logical problem-solving skills

Benefits

• Comprehensive benefits package worth approximately one-third of salary compensation
• Among the best benefits programs in the health care field

Pay

Details on pay are not specified in the job posting.

Schedule

Schedule details are not specified in the job posting.

Blue Cross & Blue Shield of Mississippi is an Equal Opportunity Employer

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.