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Compliance Audit Services Specialist, Experienced

Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California is focused on transforming health care by making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 3.5 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution. We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.  Description  Compliance and Risk Management - Develops, maintains, and implements policies, procedures and interventions for ensuring that Blue Shield CA?s activities are conducted in compliance with relevant regulations, laws and standards and to prevent illegal or improper conduct. Compliance Audit Services Specialist - Audits claims for coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures. Selects claims through random processes and/or other criteria. Responds to audit rebuttals. Essential Responsibilities: Responsible for performing production and quality control audits for internal claims and external Medicare, HMO or PPO providers. Assures compliance to in-house and/or external specifications and standards. Conducts comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model. Responsible for revision of policies and procedures to comply with regulatory changes and for training internal staff or delegated providers. Model includes monitoring and review of self-reported compliance, developing an audit plan, executing the audit, identifying corrective action opportunities, creating a final report, and following up on outstanding issues. Responsible for monitoring and reporting operational timeliness of providers that assures compliance to in-house and/or external specifications and standards. Responsible for instituting corrective action for non-compliance. Negotiates corrective action plans. Participates in the development of claims training. Develops correspondence to external entities. Coordinates auditing process with external providers and internal business units. Manages internal & external data reporting on compliance, interdepartmental performance reviews, and monthly claims delegation compliance reviews. Participates in projects and taskforces as assigned. Other duties as assigned.  Qualifications  ? In-depth knowledge of applicable legislation/regulations and actively maintains compliance. ? Experience in compliance, legal services, corporate training, or a related field. ? Thorough experience in health care, legal services, privacy or investigative services. ? Strong analytical and problem-solving skills. ? Typically, requires advanced knowledge of job area typically obtained through advanced education combined with experience. May have practical knowledge of project management. ? Typically, requires a college degree or equivalent experience and minimum 5 years of prior relevant experience. 18002K9
Salary Range: NA
Minimum Qualification
5 - 7 years

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