Senior Claims Audit Coordinator

Pay Range:

Please emailif you are a candidate seeking a reasonable accommodation for the application and/or interview process.

At BCBSRI our greatest resource is our people.

We come from varying backgrounds different cultures and unique experiences. We are hard-working caring and creative individuals who collaborate support one another and grow together. Passion empathy and understanding are at the forefront of everything we donot just for our members but for our employees as well.

We recognize that to do your best work you have to be your best self.
Its why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health dental and vision insurance as well as programs that support your mental health and well-being. We pay competitively offer bonuses and investment plans and are committed to growing and developing our employees.

Our culture is one of belonging.
We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where youre at in the organization youre an integral part of our team and your input thoughts and ideas are valued.

Join others who value a workplace for all.
We appreciate and celebrate everything that makes us unique from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders.

Were dedicated to serving Rhode Islanders.
Our focus extends beyond providing access to high-quality affordable and equitable care. To further improve the health and well-being of our fellow Rhode Islanders we regularly roll up our sleeves and get to work (literally) in communities all across the statebuilding homes working in food pantries revitalizing community centers and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can our associates receive additional paid time to volunteer.

What you will do:

• Coordinate equipment facilities and personnel resources for onsite audits of claim coding and benefit payments customer service calls and enrollment information to ensure organization is meeting requirements set forth in employer group account agreements. Ensure audits are planned and performed in accordance with policies and procedures. Research and respond to identified audit findings.
• Respond to requests for information as related to implementation and ad hoc audits; triage information requests as appropriate.
• Participate in reviews of claims coding and benefit payments to identify errors in processing and payment and to ensure claims are settled according to company policies and procedures.
• Conduct accuracy and/or timeliness reviews in the areas of claims inquiries or enrollment to determine whether work was performed accurately and within specified timeframes. Lead development of new processes and/ or sampling methodologies to most efficiently analyze BCBSRI performance. Utilize business knowledge to develop creative and custom methods of data retrieval for account -develop data definitions that reflect these best practices.
• Coordinate with internal business areas and external vendors to address identified errors through corrective action plans. Request and monitor system changes. Prepare audit report findings for management review and other stakeholders. Identify instances where escalation is needed and work with department leadership to drive action.
• Provide recommendations to improve the structure of the benefit updates. Track progress on action plans and compliance with target dates for departments to correct the benefits in the system.
• Lead and/ or participate in department initiatives and projects. Mentor and develop department associates to learn new processes and to problem solve challenges. Create targeted training materials for department associates.
• Perform other duties as assigned.

What youll need to succeed:

• Associates or Bachelors degree in Business Management or related field or an equivalent combination of education and experience
• Seven or more years experience in claims review processing or adjudication or experience in customer service within a health insurance organization
• Extensive knowledge of Blue Cross & Blue Shield products
• Experience conducting quality assurance reviews
• Knowledge of claims coding

• Knowledge of claims processing or membership administration for all lines of business
• Ability to research data identify trends and recommend appropriate actions
• Detail oriented
• Ability to work successfully in a matrix environment
• Demonstrated written and verbal communications skills
• Ability to exercise sound judgment
• Ability to establish and maintain strong working relationships with various stakeholders
• Ability to organize work efficiently to meet established time and quality standards
• Good organization skills
• Good time management skills
• Proficiency with Microsoft Suite of products i.e. Word Excel PPT etc.
• Proficiency with Business Objects - Crystal Reports.
• In-depth understanding of BCBSRIs data warehouses including structure and content of the Enterprise Data Repository (EDR) and Facets Backend.
• Proficiency with using EDR metadata to create custom extracts to meet targeted audit needs.

Location:
BCBSRI is headquartered in downtown Providence conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states pending approval from the Human Resources Department: Arizona Connecticut Florida Georgia Louisiana Massachusetts North Carolina Oklahoma Rhode Island South Carolina Texas Virginia
  

Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do and it strengthens our ability to meet the challenges of todays healthcare industry. BCBSRI is an equal opportunity employer.

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