Quality Specialist

Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals.  If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole-person health.

At Independence, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve. 

Job Summary

Responsibility for completing accuracy reviews of case samples for program audits.  Assesses operational and service performance of substantially all branded, core health business. The most common branded health lines of business included in the Program are: HMO, PPO, Indemnity, Traditional, Medicare Advantage, Medicare Supplemental products, Medicare Replacement products, Home, Host and Medicaid. This includes ASO functions performed by the Plan.

 All services administered by the Plans that cover enrollment, claims and customer service must be measured and reported in accordance with the BCBSA Program Guides.

 Audit documentation utilized to report performance data should be stored for a minimum of ten years following the end of the reporting period. Staff are required to create screen shot packets and retain all transactions, policies, documents, etc., and be able to recreate the audit in its entirety if needed. This includes, but is not limited to:

Ø The enrollment application

Ø The 837, CMS 1500, or UB-04

Ø The phone call

Ø The provider contract

Ø Pricing policies

Ø Benefit policies

Ø DRG logic

Ø Bundling logic

Ø Accumulators

Responsibilities

1. Review transactions to ensure completeness and accuracy by using information available within the Plan for monthly case samples.  Case reviews are done back to source documents which includes but is not limited to:
   1. Signed/Acknowledged group/member benefit contracts as well as at time the Sales Approved group benefit Product Configurator System 
   2. Provider contracts for facility and professional services with review of specific detail on pricing requirements within the contracts (reading and assessing information within the contracts as defined by the various BCBSA Guide requirements)
   3. Pricing fee schedules for providers along with calculations for specific defined pricing polices for varying types of services, assessment for pricing detail is from sources in the plan prior to any upload to the processing system
   4. Understanding and reading data files (i.e., HIPAA 837/834) from groups and providers for member and claim details to assess the processing systems are accurately reflecting the details submitted
   5. Provider data demographics from provider credential documents, provider portals, letters, phone calls to providers or other sources in the provider network business area
2. Auditing against the methods and requirements as deemed compliant by the various BCBSA Program Audit Guides. 
3. Creating audit packet documents as our plan’s internal source for evidence of what was reviewed during the sample case assessment.  Packets include screen shots of all source documentation assessed at the time of the case review and any pertinent IBC policy provisions that are part of the case determination as defined in the program requirement guides  
4. Monitor deadlines and serve as a technical liaison when appropriate for sample transaction questions
5. Assess regulations for compliance of audit reviews per program audit guidelines, required data sources and incorporate what is required into the specifications and/or documentation
6. Identifies trends related to findings, reports audit outcomes as needed to related business units, and support or implements enhancements based on results with appropriate personnel 
7. Tracks pended case issues and makes recommendations for improvements

1. Communicate effectively in writing and verbally with in work groups and internal and external customers
2. Attend internal and external education training to achieve and maintain proficiency on all systems
3. Meet required audit deadlines and quality standards