Quality Control Claims Audit Technician-Claims processing-Medicare/Medicaid expe
Blue Cross Blue Shield of Arizona, Phoenix, AZ, United States
Overview
Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:
Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week
Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week
Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month
Onsite: daily onsite requirement based on the essential functions of the job
Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building
Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.
This position is hybrid within the state of AZ only.
This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona.
Purpose of the job
Performs internal audit reviews. Ensures accurate payment for all claim types and verifies demographic information is loaded correctly in accordance with the Arizona Health Care Cost Containment System and the Centers for Medicare and Medicaid services requirements, rules, regulations, and contract agreements.
Qualifications
REQUIRED QUALIFICATIONS
Required Work Experience
Levels 1 and 2:
3 years in a managed care environment
3 years of claims processing
2 years of processing or auditing Medicaid or Medicare Part A and B claims
Level 3:
4 years in a managed care environment
3 years of claims processing
3 years of processing or auditing Medicaid and Medicare Part A and B claims
Required Education
High-School Diploma or GED in general field of study (Applies to All Levels)
Required Licenses
N/A
Required Certifications
N/A
PREFERRED QUALIFICATIONS
Preferred Work Experience
(Applies to All Levels)
N/A
Preferred Education
Associate's Degree in Business or Healthcare field of study. (Applies to All Levels)
Preferred Licenses
N/A
Preferred Certifications
Certified Professional Coder (applies to all levels)
ESSENTIAL job functions AND RESPONSIBILITIES
Level 1
Ensures the quality of work within the organization by performing random quality audits of claims processed for one audit type or Line of Business.
Performs audits on provider information and/or Contracts.
Researches root cause of claim issues, determines corrective action to resolve it, communicates and documents findings.
Applies new information (e.g. AHCCCS policies, AHCCCS encounter changes, Medicare procedures and processes, etc.) to the audits.
Analyzes and documents audit results by tracking and trending audit results and report findings.
Identifies process improvements opportunities.
Supports the audit needs of the organization by completing ad-hoc analysis and reports upon request.
Performs other duties as assigned by completing other tasks as assigned to assist with operations of the internal department and other functional areas.
Level 2
Ensures the quality of work within the organization by performing random quality audits of claims processed.
Conducts financial accuracy audits on all claims paid greater than a value of $2,500.00.
Level 3
Applies and communicates new information (e.g. AHCCCS policies, AHCCCS encounter changes, Medicare procedures and processes, etc.) to the audit staff and/or other departments, assist in the maintenance of templates and forms and ensure their distribution to applicable departments and staff.
Supports the internal audit team by answering job-related technical questions, transfers knowledge through training, assist with assigning and monitoring workload, train new internal auditors and assist in the development and maintenance of training materials, including but not limited to: desk reference manuals, Medicaid and Medicare updates.
Cross-train levels 1-2 auditors
All Levels
Each progressive level includes the ability to perform the essential functions of any lower levels and assist / mentor employees in those levels.
The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
Perform all other duties as assigned.
Competencies
Required Competencies
Required Job Skills
(Applies to All Levels)
Strong experience on different payment methodologies
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
Intermediate PC proficiency
Intermediate proficiency in spreadsheet, database and word processing, and presentation software
Knowledge of medical terminology
Knowledge of ICD-10-CM and PCs
Knowledge of CPT Codes and HCPCs codes
Knowledge of Medicaid and Medicare rules, regulations and guidelines
Claims processing/Auditing
Knowledge of all claim forms and types (UB04, 1500 and ADA)
Required Professional Competencies
(Applies to All Levels)
Analytical skills to support independent and effective decisions
Prioritize tasks and work with multiple priorities, sometimes under limited time constraints.
Perserverance in the face of resistance or setbacks.
Effective interpersonal skills and ability to maintain positive working relationship with others.
Verbal and written communication skills and the ability to interact professionally with a diverse group, executives, managers, and subject matter experts.
Working knowledge of HIPAA and privacy requirements
Maintain confidentiality and privacy
Analytical knowledge necessary to generate reports based on available data and then make decisions based on reported data
Preferred Competencies
Preferred Job Skills
(Applies to All Levels)
Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones
Advanced PC proficiency
Advanced proficiency in spreadsheet, database and word processing software
Preferred Professional Competencies
(Applies to All Levels)
Identify solutions to meet customer needs
Work with ambiguous and conflicting information while keeping focused on the end goal.
Preferred Leadership Experience and Competencies
(Applies to All Levels)
N/A
Our Commitment
AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
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Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:
Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week
Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week
Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month
Onsite: daily onsite requirement based on the essential functions of the job
Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building
Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.
This position is hybrid within the state of AZ only.
This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona.
Purpose of the job
Performs internal audit reviews. Ensures accurate payment for all claim types and verifies demographic information is loaded correctly in accordance with the Arizona Health Care Cost Containment System and the Centers for Medicare and Medicaid services requirements, rules, regulations, and contract agreements.
Qualifications
REQUIRED QUALIFICATIONS
Required Work Experience
Levels 1 and 2:
3 years in a managed care environment
3 years of claims processing
2 years of processing or auditing Medicaid or Medicare Part A and B claims
Level 3:
4 years in a managed care environment
3 years of claims processing
3 years of processing or auditing Medicaid and Medicare Part A and B claims
Required Education
High-School Diploma or GED in general field of study (Applies to All Levels)
Required Licenses
N/A
Required Certifications
N/A
PREFERRED QUALIFICATIONS
Preferred Work Experience
(Applies to All Levels)
N/A
Preferred Education
Associate's Degree in Business or Healthcare field of study. (Applies to All Levels)
Preferred Licenses
N/A
Preferred Certifications
Certified Professional Coder (applies to all levels)
ESSENTIAL job functions AND RESPONSIBILITIES
Level 1
Ensures the quality of work within the organization by performing random quality audits of claims processed for one audit type or Line of Business.
Performs audits on provider information and/or Contracts.
Researches root cause of claim issues, determines corrective action to resolve it, communicates and documents findings.
Applies new information (e.g. AHCCCS policies, AHCCCS encounter changes, Medicare procedures and processes, etc.) to the audits.
Analyzes and documents audit results by tracking and trending audit results and report findings.
Identifies process improvements opportunities.
Supports the audit needs of the organization by completing ad-hoc analysis and reports upon request.
Performs other duties as assigned by completing other tasks as assigned to assist with operations of the internal department and other functional areas.
Level 2
Ensures the quality of work within the organization by performing random quality audits of claims processed.
Conducts financial accuracy audits on all claims paid greater than a value of $2,500.00.
Level 3
Applies and communicates new information (e.g. AHCCCS policies, AHCCCS encounter changes, Medicare procedures and processes, etc.) to the audit staff and/or other departments, assist in the maintenance of templates and forms and ensure their distribution to applicable departments and staff.
Supports the internal audit team by answering job-related technical questions, transfers knowledge through training, assist with assigning and monitoring workload, train new internal auditors and assist in the development and maintenance of training materials, including but not limited to: desk reference manuals, Medicaid and Medicare updates.
Cross-train levels 1-2 auditors
All Levels
Each progressive level includes the ability to perform the essential functions of any lower levels and assist / mentor employees in those levels.
The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
Perform all other duties as assigned.
Competencies
Required Competencies
Required Job Skills
(Applies to All Levels)
Strong experience on different payment methodologies
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
Intermediate PC proficiency
Intermediate proficiency in spreadsheet, database and word processing, and presentation software
Knowledge of medical terminology
Knowledge of ICD-10-CM and PCs
Knowledge of CPT Codes and HCPCs codes
Knowledge of Medicaid and Medicare rules, regulations and guidelines
Claims processing/Auditing
Knowledge of all claim forms and types (UB04, 1500 and ADA)
Required Professional Competencies
(Applies to All Levels)
Analytical skills to support independent and effective decisions
Prioritize tasks and work with multiple priorities, sometimes under limited time constraints.
Perserverance in the face of resistance or setbacks.
Effective interpersonal skills and ability to maintain positive working relationship with others.
Verbal and written communication skills and the ability to interact professionally with a diverse group, executives, managers, and subject matter experts.
Working knowledge of HIPAA and privacy requirements
Maintain confidentiality and privacy
Analytical knowledge necessary to generate reports based on available data and then make decisions based on reported data
Preferred Competencies
Preferred Job Skills
(Applies to All Levels)
Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones
Advanced PC proficiency
Advanced proficiency in spreadsheet, database and word processing software
Preferred Professional Competencies
(Applies to All Levels)
Identify solutions to meet customer needs
Work with ambiguous and conflicting information while keeping focused on the end goal.
Preferred Leadership Experience and Competencies
(Applies to All Levels)
N/A
Our Commitment
AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
#J-18808-Ljbffr