Grade 05

POSITION PURPOSE

This position is responsible for reviewing transactions processed by the operational departments, identify trends and systemic irregularities to improve quality performance. Documents reviews in the Quality Tracking System (QTS), then reports results to management and processor. Conducts reviews of operational areas to determine compliance with all relevant policies, regulations, and procedures. Accountable for complying with all laws and regulations associated with duties and responsibilities.

• This role does not manage people
• This role reports to this job: SUPERVISOR, OPERATIONAL LEARNING & PERFORMANCE
• Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with:
  
  All areas of Benefits Operations, IT, Sales and Marketing, BCLI, District Offices, Team Leaders, Managers, Directors, Provider Contracting, Medical Management, and other employees as needed.
  
  May contact the following routinely or on an as needed basis: legal, brokers, subscribers, providers, and other insurance carriers.

• High School Diploma or equivalent is required

• 3 years in either Enrollment & Billing and/or Claims analyzing transactions is required

• Must have knowledge in the processes and produces (i.e., claims processing and/or enrollment coding) is required
• Must have working knowledge of relevant software (MS Word, Excel, Outlook, etc.) and related software as other corporate programs and applications, including but not limited to Facets, Common Query, and CMOD.
• Must have strong organizational and analytical abilities and effective interpersonal skills.
• Must demonstrate verbal and communication skills with the ability to interpret and communicate information with tact, diplomacy, patience and professionalism.
• Able to cohesively work in a team environment to ensure efficient and effective completion of all tasks for assigned groups.
• Able to shift priorities as needed to cover multiple tasks in the process as directed by leadership.
• Must have working knowledge about plan products, company initiatives and other operational changes affecting the department.

• None Required

• Reviews Benefit Operations transactions (i.e., Claims and Enrollment & Billing) to identify accuracy and inaccuracy of services and processes. Reviews all processed work pending for review with established manuals and other information for correct coding in all systems related to type of work reviewed. Prepares reports of findings. Informs management of findings to suggest and advise if education and training is necessary on processing practices and compliance issues.
• Trains, instructs, coaches and/or provides technical support to all new reviewers, trainees in client units, and Quality Management Analysts as well as IT Analyst as appropriate regarding benefits, compliance, new procedures, and system problems as detected.
• Conducts reviews of operational areas to determine compliance with all relevant policies, regulations, and procedures.
• Researches, analyzes, and responds to inquiries regarding compliance and accuracy.
• Conducts audits of operational areas while maintaining a log of all special audit cases, reporting savings to management, assisting audit coordinators with technical aspects of benefit operational review and training, instructing, coaching and/or providing technical support to all new auditors, trainees in client units and Quality Management staff as well as IT Analysts, as appropriate, regarding coding, benefits, adjustment procedures, compliance, new procedures and system problems as detected.
• Resolves errors contested by managers and recognizes and/or adapts changing guidelines and requirements diplomatically in order to maintain relationships with benefit operational areas to ensure audit accuracy.
• Reviews all Benefit Operational transactions (i.e., Claims and Enrollment & Billing) including but not limited to releasing claims for final adjudication to service subscribers and providers, researching and clearing edits, recalculating payments, identifying, screening claims for indication of possible fraud and/or abuse, and working with internal/external personnel for clarification to ensure claims accuracy and effectiveness of the claims processing system. Verifies effective dates and coverage. Assures all information sent to groups are accurate and correct and corresponds with information received. Verifies applications for the group and member files including health, life, dental, drugs, and primary care physicians according to HIPPA guidelines.
• Verifies applications for the group and member files including health, life, dental, drugs, and primary care physicians according to HIPPA guidelines. Maintains log of all special review cases and reports findings to management. Assists internal audit coordinators with technical aspects of membership review. Assures all information sent to groups in accurate and correct and corresponds with information received.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

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