Quality Assurance Specialist

Job Summary

The Quality Assurance Specialist is responsible for auditing a wide variety of operational transactions encompassing enrollment, claims and inquiry processes as defined in Blue Cross Blue Shield Association (BCBSA) quality assurance (QA) programs and performance guarantees agreements with key accounts. The position validates the accuracy and timeliness of system and manual processes related to the processing and payment of claims, setup of groups, products and members and responds to multi-channel inquires from members, providers and other Plans. A key function of this role is collaborating with operations management to confirm and initiate resolution of quality and timeliness issues. 

Essential Functions

• Performs comprehensive audits of claims, applications, inquiries, and transmittals in comparison to source documents, and ensures these reviews lend to accurate and timely operations. Pulls working documents and other auditable transactions from electronic systems and generates reports when necessary. Handles audit function in a self-directed and process-driven manner including making appropriate determinations on the samples utilized in random sampling reviews.
• Partners cross-functionally with operations management and departmental subject matter experts to research findings, make final error determinations and initiate issue resolution. Works with operational departments to educate and reinforce best practices and guidelines which promote an overall focus on quality.
• Tracks and reports performance results to plan executives, operations management and key operations staff. Submits necessary QA related reports or documentation to the association or other external agencies, as appropriate.
• Coordinates, conducts and facilitates external audits, focused reviews and control plan pricing requests.
• Maintains audit work papers, supportive documentation, findings, reports and emails.
• Maintains and updates procedures and timelines.

Knowledge, Skills and Abilities

Attention to Detail and Accuracy

Intermediate

Collaboration

Intermediate

Quality Focus

Intermediate

Problem Solving and Resolution

Basic

Communication (Verbal/Written)

Basic

Education Requirements

Required: Associate's

Preferred: Associate's

Field(s) of Study: Business, Healthcare Administration or related field

Experience Requirements

Required: Minimum of 3 Years

Preferred: Minimum of 3 Years

Experience Details: Minimum of 3 years of healthcare, insurance, quality assurance or related experience is required.

Certification, Licensures & Registration Requirements

Title: N/A

State or Agency: N/A

Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards

Other Information

Job Posting Policy 6.05

New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.

Equal Opportunity Employment

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email careers@bcbsnd.com

This job posting will be closed 5/24/2019 at 8:00AM CST. No further applications will be considered.