Your Role
The Operations Audit Oversight team (within the Claims Organization) partners with external audit firms, regulators and internal partners to support required audits. The Experienced Compliance Audit Services Specialist will report to the Senior Manager of the Claims Partnerships and Communications team. In this role you will have the opportunity to work with a dynamic team auditing claims, investigating root cause, proactively auditing through data analysis as well as claims research, and support the Calpers Account.
Your Work
In this role, you will:
- Conduct comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model and assure compliance to in-house and/or external specifications and standards
- Be responsible for revision of policies and procedures to comply with regulatory changes and for training internal staff
- Manage internal & external data reporting on compliance, interdepartmental performance reviews, and monthly claims delegation compliance reviews
- Leverage your claims knowledge to initiate resolution at the root cause of issues and ensure avoidance of future issues
- Have the ability to work with internal partners to facilitate issue resolution
- Combine your passion for claims with your ability to identify larger scale claims issues with data analysis
- Communicate with different audiences who may need various levels of information, and you will use your communication expertise to share information clearly
- Be a critical member of a collaborative, fantastic team
Your Knowledge and Experience
- Requires a bachelor's degree or equivalent experience
- Requires at least 3 years of prior relevant experience
- Requires an analytical mindset, ability to determine root cause of a claims issue, as well as upstream and downstream impacts
- Requires an agile attitude, ability to change directions and prioritization when needed
- Requires excellent communication skills, and the ability to translate claims processing information / processing rules into language all can understand - inside and outside of this organization. Requires knowledge of MS Office Applications, and perform claims analysis in Excel. Preferred knowledge and/or ability to run reporting in Business Objects
- Requires Facility and Professional claims processing knowledge and experience and the FACETS system.
- Prefer candidates with knowledge of Self-Funded business; and will require a specific understanding of Calpers' benefits and processing rules
Pay Range:
The pay range for this role is: $71,280.00 to $99,770.00for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
