Quick overview
SeniorityMid Senior
Work modeHybrid
LocationDetroit, United States
Microsoft OfficeProcess ImprovementRoot Cause Analysis
Job description
Responsible for analyzing, reconciling and reporting quality team activities and audit results for individuals and department. Uses data to identify trends and root causes of problems; participates in cross functional efforts with other staff and leaders to address those problems. Works with BCBSM quality assurance staff to validate or dispute MTM findings and report findings to the corporation.
- Compile, analyze and calculate accuracy scores for individual, team training, MTM, high dollar and high error rate reports.
- Create and research detail on root cause analysis and trends.
- Administer MTM process including disputes.
- Audit quality team review staff.
- Handle first level appeals from claims staff regarding quality findings and error assignments.
- Act as a liaison between quality team and partner departments to address issues such as ensuring all adjustments are completed as identified through quality audits, reviewing new or modified procedures for accuracy in conjunction with Document Training Specialists and working with claims process improvement area and leadership to respond to and/or monitor audit activity on behalf of department for internal and external reviews and audits.
- Gather, analyze and report trends in quality results and work with leaders and other staff areas to correct the underlying causes of errors.
- Complete special projects as assigned.
- Other duties may be assigned.
"Qualifications"
- Two (2) years college in business or health care related field
. - Three (3) years operational experience in health care setting which includes two (2) years of claims processing or inquiry resolution experience with Facets system.
- Experience working effectively in a team environment.
- Experience in BCN Claims Quality area preferred.
- Excellent problem solving skills including the ability to analyze, identify and communicate recommendation regarding quality trends and process improvement opportunities.
- Prioritization, organizational and self motivation skills necessary to work independently on multiple tasks and changing priorities within expected timeframes.
- Excellent written and verbal communication skills in order to effectively communicate complex or technical information excellent interpersonal skills including the ability to interact with all levels of external and internal customers.
- Demonstrated knowledge of Microsoft Office Suite and related PC software.
- Experience documenting issues, processes and workflows preferred.
Other related skills and/or abilities may be required to perform this job.
Departmental Preferences:
- Experience with MA PPO claim experience and NASCO experience is preferred.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.