Medical Management Auditor Job

Overview

For more than 80 years, Blue Cross and Blue Shield of Minnesota has been passionate about improving health. We provide quality, cost-effective health plans and innovative programs that make a healthy difference in people’s lives. Blue Cross is the largest health plan based in Minnesota, covering nearly 3 million members in the state and across the country. We strive to help all Minnesotans overcome the barriers to good health.

 

We offer our employees a comprehensive benefits, compensation and total rewards package to keep you and your family healthy and to secure your financial future. Our Employee Resource Groups help us advance health equity while promoting a diverse and inclusive work environment. Join us and make a healthy difference in people’s lives through the work you do every day. Together, we’ll make Minnesota a better place to live — and a healthier one.

Description Summary

This position supports the centralized function of auditing and analysis to obtain operational quality within Medical Management for case management, disease management, utilization management and access management. This role will promote consistency and ensure compliance with regulatory requirements by both clinical and non-clinical staff. This position will provide input into the development and maintenance of the audit tools, development of reports for trend analysis, identification of performance gaps and training opportunities.

Accountabilities

  1. Continuously performs audits on medical management functions such as case management, disease management and utilization management for clinical and non-clinical positions to ensure operational quality expectations and regulatory standards are met.
  2. Utilize knowledge of data analysis tools and technology to identify and validate risks
  3. Documents audits and provides detailed results and feedback to leadership for individual and team results.
  4. Conducts initial evaluation of error origin and seeks trends in data to determine operational efficiencies and recommend process improvements.
  5. Participates in the review, development and implementation of divisional audit tools.
  6. Effectively responds to and resolves disputes of audit findings working with various levels of leadership.
  7. Drives to and delivers high quality solutions with aggressive timeframes and high level stakeholder satisfaction.
  8. Develops presentations highlighting findings, analysis, recommendations and action plans.
  9. Maintains a high degree of professionalism and confidentiality.
  10. Complete special projects as assigned by management.
  11. Performs other accountabilities as assigned.

Requirements

  • Registered Nurse.
  • 3 years of health related experience or equivalent military experience.
  • Well developed understanding of medical/behavioral health terminology and health management process and procedures.
  • Broad knowledge of care management and regulatory and accreditation standards.
  • Demonstrated track record of achievement with ability to identify and deliver customer expectations.
  • Strong verbal and written communication skills.
  • Demonstrated ability to work independently and make decisions as needed.
  • Proficient PC navigation and application skills.
  • Demonstrated ability to evaluate and interpret data.
  • Strong organizational skills and flexibility to work additional hours as necessary to meet deadlines.

Preferred Requirements

  • 3 years of health related auditing experience.
  • Degree in nursing and 3 years relevant clinical or managed care experience.
  • Proficient with Microsoft Office Suite.

FLSA Status
Exempt

Blue Cross Blue Shield of Minnesota is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.

Make a difference

Thank you for your interest in Blue Cross. Be part of a company that lets you be you — and make a healthy difference in people’s lives every day

Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association