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JOB SUMMARY
This job conducts audit review of finalized claims, adjustments and customer service activities. Evaluating the accuracy of claims inquiries and adjustments against BCBSA and FEP guidelines, government regulations, corporate and departmental policies and procedures, contractual guidelines, benefit booklets and any other related requirements applicable.
ESSENTIAL RESPONSIBILITIES
1. Audits – conduct independent review of transaction to evaluate:
2. Audit Documentation – research, acquire and maintain current and reliable reference documentation required to conduct each audit review in order to support findings and satisfy potential audits by BCBSA, FEP, etc.
3. Resolution of Audit Findings – accurate and complete reporting of audit findings
4. Other duties as assigned or requested.
EDUCATION
Required
Substitutions
Preferred
EXPERIENCE
Required
Preferred
LICENSES or CERTIFICATIONS
Required
Preferred
SKILLS
Language (Other than English):
None
Travel Requirement:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Rarely
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Never
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$19.66Pay Range Maximum:
$27.42Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and Applicants Notice