Quality Assurance Specialist Iii (Remote)

Resp & Qualifications

PURPOSE:

The Quality Assurance Specialist III is an advanced-level auditor position performing in-depth system and procedural audits. This role conducts regular reviews and audits of internal controls within the claims and Other Party Liability (OPL) areas, for strengths and weaknesses ensuring special focus to the specific risk areas. The incumbent is considered a Subject Matter Expert (SME) in their audit field and provides a comprehensive analysis of claims transactions, systems, and procedures, Medicare Secondary Payor (MSP) claims, and Coordination of Benefits (COB).

ESSENTIAL FUNCTIONS:

• Audits assigned function claims and Other Party Liability (OPL) cases for accuracy, benefit payment and compliance with policies and procedures. Identifies, documents and reports transaction errors utilizing departmental quality monitoring templates in a timely manner to ensure prompt resolution. Coach and mentor Quality Assurance Specialist Level I and II associates and performs weekly and monthly audits.
• Assists in development of special department projects and participates in department and divisional projects.
• Conducts structured coaching and feedback sessions. Provides suggestions and creates improvement plans for areas of deficiency within the group or for an individual.
• Participates in the creation and implementation of new methods, processes and/or products.

SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level: High School Diploma or GED.

Licenses/Certifications:

• ECA Certified Quality Assurance Manager.

Experience: 5 years Auditing, Quality Assurance, Operations, Training, Project Management, or comparable work experience. 2 years current experience as a Claims and Other Party Liability (OPL) Quality Assurance Specialist II. Subject Matter expert with Medicare Secondary Payor claims and OPL case resolutions.

Preferred Qualifications:

• Current Claims and Other Party Liability auditing experience.
• Medicare Secondary Payor claims knowledge and case resolution.

Knowledge, Skills and Abilities (KSAs)

• Knowledge of Quality Assurance and production technologies.
• Proficient in Microsoft Office programs.
• Extensive of industry standards, quality control techniques and procedures.
• Excellent communication skills both written and verbal.
• Extensive analytical and problem-solving skills.
• Strong interpersonal skills.
• Excellent research and organizational 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: $51,552 - $102,388

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

Claims Processing

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified 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

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