Medical Management Auditor

About Blue Cross Blue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We’re committed to reinventing health care to improve health for our members and the community. We hope you'll join us. How Is This Role Meaningful to Our Work? 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. A Day in the Life: 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 collaborator satisfaction. Develops agendas and facilitates meetings with collaborators to present findings related to audit results, analysis, recommendations, and action planning. Participates in various meetings and trainings as a subject matter expert to find opportunities and/or risks associated with UM and CM process changes. Conducts Quality of Care (QOC) case reviews which includes: case triage, conducting medical record research and investigation for a clinician level review (which may include letters to providers) and determining if case requires escalation to a medical director. Renders outcome to non-escalated cases. Collaborates with medical directors with escalated QOC cases. This could include a joint presentation of a case at QOC subcommittee. Maintains a high degree of professionalism and confidentiality. Completes special projects as assigned by management. Performs other accountabilities as assigned. Nice to Have: 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. Required Skills and Experiences: Registered Nurse. 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 and interpret data. Strong organizational skills and flexibility to work additional hours as necessary to meet deadlines. Role Designation: Teleworker Role designation definition: Teleworking is working full time remote. Hybrid is a combination of working onsite and remotely. Onsite is full-time onsite. Make a difference 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, gender expression, or any other legally protected characteristic. Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to talent.acquisition@bluecrossmn.com. All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S. Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association. Chartered in 1933 as Minnesota’s first health plan, this company is one of the most recognized and trusted health care brands in the world. It has more members, the largest network of doctors, and more products and services than any other health plan in Minnesota. Headquartered in Eagan, Minnesota with offices in North Minneapolis and Virginia and retail centers in Edina, Roseville and Duluth. Affiliate Companies' Jobs