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Compl Audit Srvcs Int Job
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| Employer Name: |
SpiderID: 13843441 |
| Location: Woodland Hills, California |
Date Posted: 9/20/2024 |
| Wage: Negotiable |
Category: Insurance |
| Job Code: 17002G1-2191 |
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Job Description:
 Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California's Mission is to ensure all Californians have access to high-quality care at an affordable price. Blue Shield is focused on improving health care delivery by working closely with providers and making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 4 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than $325 million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution.
We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.
Description:
JOB DESCRIPTION
Responsibilities include:
- Responsible for performing production and quality control audits for internal claims and external Medicare, HMO or PPO providers.
- Assures compliance to in-house and/or external specifications and standards.
- Conducts comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model.
- Responsible for revision of policies and procedures to comply with regulatory changes and for training internal staff or delegated providers.
- Model includes monitoring and review of self-reported compliance, developing an audit plan, executing the audit, identifying corrective action opportunities, creating a final report, and following up on outstanding issues.
- Responsible for monitoring and reporting operational timeliness of providers that assures compliance to in-house and/or external specifications and standards.
- Responsible for instituting corrective action for non-compliance and negotiates corrective action plans.
- Participates in the development of claims training.
- Develops correspondence to external entities.
- Coordinates auditing process with external providers and internal business units.
- Manages internal & external data reporting on compliance, interdepartmental performance reviews, and monthly claims delegation compliance reviews.
- Participates in projects and taskforces as assigned.
- Works under general supervision and able to function independently to produce results that meet standards of quality, timeliness and acceptability.
- Responsible for assignments ranging from routine to moderate in scope and complexity.
- Makes decisions on routine matters where established policies and procedures are available.
- A certain degree of creativity and latitude is required.
Qualifications:
Education/Requirements:
- Generally requires a Bachelor's degree or equivalent work experience
- Moderate to thorough experience in managed care setting, health care industry or related field.
- Master's degree may be preferred.
- 20% travel required.
Job Criteria:
Start Date:
Position Type: Full-Time Permanent
Years of Experience Required:
Education Required:
Overnight Travel:
Vacation Time:
Contact Information:
| Contact Name: Blue Shield of California |
Company Type: |
| Company: Blue Shield of California |
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