Ops Auditor I - 014918 at Excellus Health Plan Inc. in binghamton, New York

Job Description:

Summary:

In accordance with audit criteria and guidelines established by the BCBS Association and/or State or Federal mandates, the incumbent performs audits to determine conformance with specified contract benefits, regulations and corporate policies. Operations Auditors also assist with the performance of external, inter-plan and SSAE 16 audits. A summary of each position grade is provided below:

Specific to Lifetime Benefit Solutions (LBS)
• Audit focus on benefit plan building, stop loss activity, 401K distribution, and payroll activity.

Operations Auditor I
Under the guidance of the Assigned Management, the Operations Auditor I is responsible for planning, organizing, performing audit assignments, internal reporting and following up on specific audit assignments. These assignments are performed to provide an independent and objective assurance concerning the accuracy of claims payments, membership, customer service inquiry, as well as the effectiveness and efficiency of operations, including safeguards and compliance with applicable laws, regulations and corporate policies.

Operations Auditor II
Under the guidance of the Assigned Management, Operations Auditor II performs similar functions as the Operations Auditor I, as well as, assumes responsibility for directing the activities of a Operations Auditor I. This position reviews their work for scope, accuracy and adherence to both departmental and professional standards.

Quality/Operations Auditor III
Under the guidance of the Assigned Management, the Operations Auditor III not only performs functions similar to the Operations Auditor I & II, but also may occasionally act as a Lead Operations Auditor and/or coordinator of cross-regional functions and performs statistical data collecting and reporting. The Operations Auditor III may be responsible for directing the activities of the Operations Auditor I and Operations Auditor II by reviewing their work for scope, accuracy and adherence to both departmental and professional standards. Additionally may be required to complete Model Audit Rule Testing for various SOX and control audits.

Essential Responsibilities/Accountabilities
Operations Auditor I
• Performs audits in accordance with BCBSA, State and Federal guidelines, client contracts, corporate policies and procedures and regulatory mandates.
• Audits are performed for all EHP branded product lines and Univera subsidiary products. Audit scope includes but is not limited to the three primary operational areas: claims payments including high dollar pre-paid claims, customer service inquiries, membership & billing transactions.
• Auditing is also performed on EHP claim processing vendors, PFM transactions and Provider partnership facilities.
• Additional free-standing claim systems audited are PBM vendor systems, FEP Direct Operations system and the Dental claim processing system.
• Audits require evaluation and research to obtain pertinent claim information including contacting physicians, facilities, groups, subscribers, and other insurance companies. Additional requirements are accurate interpretation of member and provider contract language to ensure appropriate application of benefits.
• Facilitate the setup of audits including, but not limited to, importing flat files for claims.
• Assists with the performance of external audits with direction from a Quality/Operations Auditor II or III and/ or management.
• Responsible for auditing and producing performance statistics for all performance guarantee groups for which the Health Plan and/or LBS has engaged in special contracts requiring external reporting to these groups.
• Independently coaches and mentors Operational staff according to business need including Live Monitoring, Customer Care Conversation Strategy coaching and calibration sessions.
• Provides individual and group coaching recommendations based on audit results. Provides individual staff performance review summaries to supervisors for Customer Care.
• Acts as an information resource to the organization; conducts and participates in cross-training programs.
• Remains current with relevant legislative and regulatory mandates to ensure activities are in compliance with these requirements. Also, be aware of all local, regulatory, operational, and national policy changes.
• Adheres to and meets established deadlines as required by management.
• Intra-departmental reporting consisting of data input to document monthly work and performance measures.
• Proposes recommendations for system enhancements, workflow modifications, processing guidelines, system documentation and/or training documentation.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values and adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Specific to LBS
• Has authorization to release claims not exceeding $100,000.
• Audits benefit plan building, 401K distribution, payroll activities and stop loss activities.
• Understands, enforces, and educates employees in policy and procedures through auditing.

Operations Auditor II - performs similar functions as the Operations Auditor l, and can be differentiated by the following:

• Assists with the training of the Operations Auditor I staff.
• Analyzes performance data, identifies trends, and raises questions regarding policy interpretation throughout all areas of Health Plan and/or LBS including Operations, Marketing, Finance, Medical Policy and Information Technology.
• Discusses observed inconsistencies and errors with management to identify root causes of errors, verifies findings, communicates results, and initiates payment recovery/reimbursement and acts in a consulting capacity for management to ensure that remediation plans are accurate, effective and timely.
• Performs consulting duties that improve operational effectiveness and assist in the development or modification of processing guidelines, workflow modification, system enhancements and system documentation to improve operational reliability and efficiency.
• Assist with the overall management and facilitation of on-site external audits including, but not limited to, preparing source documentation, facilitating the on-site review and completing responses to draft audit reports.
• Prepare complete and consistent work papers to document inconsistencies and calculate results for each performance measure using Excel and Access. Reports are used by senior management to monitor corporate performance and determine if individual units are meeting established goals.
• Conduct special projects in the areas of statistical data collection and analysis at the request of executive management.
• Strong verbal/written communication skills external to EHP including system vendors, external auditors, legal representatives, BCBSA staff and group representatives.
•

Specific to LBS
• Has authorization to release claims not exceeding $200,000.
• Audits benefit plan building, 401K distribution, payroll activities and stop loss activities.
• Understands, enforces, and educates employees in policy and procedures through auditing.

Operations Auditor III - performs similar functions as the Quality/Operations Auditor l, and can be differentiated by the following:

• Supports Team Lead, supervisor, or manager on all aspects of external audits including up-front coordination and back-end reporting.
• Coordinates specific audits such as, but not limited to MTM, LDLA, payroll or external audits from beginning to end including data compilation.
• Coordinates special projects and/or audits for cross regional functions across all Health Plan/LBS sites.
• Acts as the process lead on statistical data collection and analysis as directed by department management.
• Prepares and has the capacity to make presentations to executive management and the senior leadership team as requested or deemed necessary by department management.
• As needed, may be asked to complete Model Audit Rule (MAR) testing of internal operational controls for effectiveness for the Sarbanes-Oxley (SOX) initiative.
• As needed may be asked to complete MAR testing of operational areas including, but not limited to Membership, Claims, and Dental controls on Facets, ERISCO and Javelina.

Specific to LBS
• Has authorization to release claims not exceeding $250,000.
• Audits benefit plan building, 401K distribution, payroll activities and stop loss activities.
• Understands, enforces, and educates employees in policy and procedures through auditing.

Minimum Qualifications
NOTE:
We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

Operations Auditor I
• Bachelor Degree with proficiency in mathematics/statistics or equivalent work experience preferred.
• Minimum of 3 years progressive experience within the corporation or related field.
• Knowledge of all Branded and Unbranded Lines of Business.
• Must have the ability to complete thorough research, exercise good judgment and work independently.
• Must have the ability to partner with peers to ensure remediation.
• Must have a working knowledge of PC's and Microsoft Office applications.
• Knowledge of multiple processing systems (Facets, MedAccess, SIR, ESI, FEP, and Univera) preferred.
• Must possess effective verbal and written communication skills.
• Must have demonstrated good interpersonal relations skills.
• Ability to manually apply multiple pricing methodologies i.e. DRG, APC, APG etc.

Quality/Operations Auditor II - requires all Operations Auditor I qualifications, plus:
• Minimum 5 years progressive experience within the corporation or related field.
• Thorough knowledge of all lines of business, policies and procedures.
• Must have advanced skills of PC's and Microsoft Office applications.
• Strong and effective analytical skills are required, along with the capacity to identify and understand business objectives and associated risks of the operational area under review.
• The ability to perform sound data analysis and problem-solving skills that include making recommendations to change or improve operational processes.

Operations Auditor III - requires all Operations Auditor I & II qualifications, plus:
• Professional certification as a CIA, CQA or other Operations Auditor/industry certifications (i.e. PAHM, FAHM, CPC etc.) is preferred.
• Minimum of 7 years progressive experience within the corporation or related field.
• Must possess leadership skills as well as the ability to effectively manage people and multiple projects.
• A demonstrated aptitude and interest in supervision.
• Relies on extensive experience and judgment to coordinate, plan and perform daily audit work.

Physical Description

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The Lifetime Healthcare Companies aim to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer