Sr. Auditor - RN Case Management at Blue Cross Blue Shield of Michigan in Detroit, Michigan

Job Description:

Responsible for assisting and supporting in the evaluation, recommendation, establishment, implementation and analysis of new and improved production workflows, work processes for systems, reporting, and new products/programs to improve customer service levels and overall quality.

• Review of medical records.


• Perform clinical reviews with knowledge of body systems, anatomy and physiology.


• Assist and support in the planning, coordination, developing and implementing of approved audit programs to enhance the overall efficiency of operational procedures, methods, controls and performance.


• Analyze, process and/or expedite operational transactions; this may include timely resolutions of problems.


• Participate in systems testing, develop procedures and controls and provide recommendations for the ongoing improvement of the updated process.


• Provide leadership team with status of projects, issue, communicate and recommend policy decisions to achieve project objectives.


• Utilize and maintain available corporate production and reporting systems; produce routine and non-routine reports, presentations, letters, communications and graphics.


• Assist internal and external personnel by answering questions and supplying information. Develop and maintain effective working relationships with customers and partners.


• Conduct and oversee training of current and new staff.


• Review letters and reports of audit staff for accuracy and completeness.


• Complete special assignments and projects as assigned.


• Serve as back up to Team Leader as needed.


• Other duties may be assigned.

Departmental Summary

Under general supervision the HCCR Unit nurse senior auditor is responsible for assessing and documentation of member utilization and prediction of future spend.  They also ensure effective and efficient post-payment review of high-cost claimants to confirm appropriate care and identify addressable cost, quality, and potential opportunity for intervention.

"Qualifications"

• Bachelor’s Degree in health-related field preferred


• Four to seven years’ experience in related field


• Two consecutive years’ experience as an analyst or auditor in Utilization Review


• Experience in operational analysis, data analysis and problem resolution types of activities


• Ability to work independently with minimal direction


• Experience with working in the Care Advance platform is preferred.


• Thorough understanding of medical coding (CPT-4 HCPCS ICD-9 or DRG) as it relates to audits.


• Ability to plan, organize direct and control projects.


• Excellent written and verbal communication skills.


• Ability to lead and contribute to process improvement projects.


• Working knowledge of PC applications and/or mainframe preferred.


• Other related skills and/or abilities may be required to perform this job


• Current, unrestricted state of Michigan RN licensure

Department Preferences

• Maintains clinical competency and keeps current on medical practices, procedures, and industry trends.


• Claims knowledge in payment policy, medical policy, and/or Inter-Plan policy preferred.


• 3-5 years’ experience in health care or insurance environment (to include utilization management, clinical audit, payment integrity, intake/customer service, health information management, and/or quality improvement)


• Ability to build relationships and work collaboratively with cross-functional teams.


• Ability to work effectively in a team environment.


• Ability to present complex cases to multidisciplinary team conference.

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.