Quality Coordinator

JOB SUMMARY

This job conducts audit review of finalized claims, adjustments and customer service activities.   Evaluating the accuracy of claims inquiries and adjustments against BCBSA and FEP guidelines, government regulations, corporate and departmental policies and procedures, contractual guidelines, benefit booklets and any other related requirements applicable. 

ESSENTIAL RESPONSIBILITIES

1. Audits – conduct independent review of transaction to evaluate:

• Accuracy of claims adjudication process as stipulated by the group contracts
• Accuracy and completeness of service responses to member and provider inquiries.
• Accuracy of enrollment processes and procedures for member applications and group benefit change forms. The review process includes:
  • Validating the actual outcome of a finalized claim against the expected outcome and payment
  • Validating the action taken to resolve an inquiry against the issues/concerns expressed by the inquirer and
  • Validating the information contained in all membership and group benefit files against the source documents received by the Plan.

2. Audit Documentation – research, acquire and maintain current and reliable reference documentation required to conduct each audit review in order to support findings and satisfy potential audits by BCBSA, FEP, etc.

3. Resolution of  Audit Findings – accurate and complete reporting of audit findings

4. Other duties as assigned or requested.

EDUCATION

Required

• High School Diploma/GED

Substitutions

• None

Preferred

• None

EXPERIENCE

Required

• OSCAR Adjustment experience
• Experience in operations’ core systems (ICIS, INSINQ, ECS, OSCAR and MEDCO) as an operational user

Preferred

• Training in Quality Assurance

LICENSES or CERTIFICATIONS

Required

• None

Preferred

• None

SKILLS

• Attention to detail

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Never

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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