Medical Management Auditor - RN

Blue Cross Blue Shield of Minnesota • Eagan, MN • 19h ago

About Blue Cross and Blue Shield of Minnesota At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us. The Impact You Will Have This position supports the centralized function of auditing and analysis to obtain operational quality within Medical Management for case management, disease management and utilization management. 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. This role will promote consistency and ensure compliance with regulatory requirements by internal associates and delegates. In addition, this role supports quality investigations. This position will work with the Health Plan Clinical Quality Coordinator to ensure compliant, effective and efficient investigations of quality issues impacting the health and service of Blue Cross and Blue Plus members are completed. This work contributes directly to the adherence with regulatory and accreditation requirements including the organizations Quality Improvement Program. Your Responsibilities Participates in the review, development, and implementation of divisional audit tools. Maintain ownership and develop audit guides in support of the audit tools. Continuously performs audits on medical management functions which requires broad knowledge of NCQA standards, state regulations and CMS guidelines. Audits capture case management, disease management, utilization management and delegate audits for clinical and non-clinical positions to ensure operational quality expectations and regulatory standards are met. Is cross-trained in all lines of business and @types of services. Utilize knowledge of data analysis tools and technology to identify and validate risks. Documents audits and provides detailed results and feedback to leadership for individual and team results. Conducts initial evaluation of error origin and seeks trends in data to determine operational efficiencies and recommend process improvements. Collaborates directly with compliance, medical policy team, accreditation, learning and development, and others when opportunities are identified. Effectively responds to and resolves disputes of audit findings working with various levels of leadership. Drives to and delivers high quality solutions with aggressive time frames and high-level stakeholder satisfaction. Develops agendas and facilitates meetings with stakeholders to present findings related to audit results, analysis, recommendations, and action planning. Participates in various meetings and trainings as a subject matter expert to identify opportunities and/or risks associated with UM and CM process changes. Maintains a high degree of professionalism and confidentiality. Completes special projects as assigned by management. Performs other accountabilities as assigned. Required Skills and Experience Registered Nurse licensure in MN. 3+ years of related professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered. 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 critical-making decisions as needed. Proficient computer navigation and application skills. Demonstrated ability to evaluate andinterpret data. Strong organizational skills and flexibility to work additional hours as necessary to meet deadlines. High school diploma (or equivalency) and legal authorization to work in the U.S. Preferred Skills and Experience 3 years of health-related auditing experience. Degree in nursing and 3 years relevant clinical or managed care experience. Case Management and Utilization Management experience. Proficient with Microsoft Office Suite. Compensation and Benefits: Pay Range: $77,200.00 - $102,300.00 - $127,400.00 Annual Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job. We offer a comprehensive benefits package which may include: Medical, dental, and vision insurance Life insurance 401k Paid Time Off (PTO) Volunteer Paid Time Off (VPTO) And more To discover more about what we have to offer, please review our benefits page. Blue Cross and 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.

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