About the position 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. 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.

Responsibilities

• 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.
• Conducts financial accuracy audits on all claims paid greater than a value of $2,500.00.
• 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
• Each progressive level includes the ability to perform the essential functions of any lower levels and assist / mentor employees in those levels.
• Perform all other duties as assigned.

Requirements

• 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
• 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
• High-School Diploma or GED in general field of study
• 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)
• 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

Nice-to-haves

• Associate’s Degree in Business or Healthcare field of study.
• Certified Professional Coder
• 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
• Identify solutions to meet customer needs
• Work with ambiguous and conflicting information while keeping focused on the end goal.