Quality Coordinator

About the role

This position conducts audit reviews of finalized claims, adjustments, and customer service activities. The role involves evaluating the accuracy of claims inquiries and adjustments against BCBSA and FEP guidelines, government regulations, corporate and departmental policies, contractual guidelines, benefit booklets, and other applicable requirements.

Responsibilities

• Audits – conduct independent review of transactions to evaluate:
  • Accuracy of claims adjudication process as stipulated by group contracts
  • Accuracy and completeness of service responses to member and provider inquiries
  • Accuracy of enrollment processes and procedures for member applications and group benefit change forms
• The review process includes:
  • Validating the actual outcome of a finalized claim against the expected outcome and payment
  • Validating the action taken to resolve an inquiry against the issues/concerns expressed by the inquirer
  • Validating the information contained in all membership and group benefit files against the source documents received by the Plan
• Audit Documentation – research, acquire, and maintain current and reliable reference documentation required to conduct each audit review to support findings and satisfy potential audits by BCBSA, FEP, etc.
• Resolution of Audit Findings – accurate and complete reporting of audit findings
• Other duties as assigned or requested

Requirements

• High School Diploma or GED (required)
• OSCAR Adjustment experience (required)
• Experience in operations’ core systems (ICIS, INSINQ, ECS, OSCAR, and MEDCO) as an operational user (required)
• Training in Quality Assurance (preferred)

Skills

• Attention to detail

Physical, Mental Demands, and Working Conditions

• Position Type: Office-based
• Teaches/trains others: Occasionally
• Travel: Regularly from the office to various work sites or from site-to-site (0% - 25%)
• Physical work site required: Yes
• Lifting up to 10 pounds: Constantly
• Lifting 10 to 25 pounds: Occasionally
• Lifting 25 to 50 pounds: Never

Pay

Base pay range: $19.66 - $27.42 per hour. Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. Geographic differentials may apply for certain locations based on comparative markets.