Hybrid Sr. Auditor en Blue Cross Blue Shield of Michigan Mutual Insurance Company

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.

QUALIFICATIONS 

• Bachelor’s degree in health-related field preferred. 
• Four (4) years of experience in related field.
• Experience required in operational analysis, data analysis and problem resolution type activities.
• Current unrestricted state of Michigan Registered Nurse license required.
• Current Registered Health Information Administrator or Registered Health Information Technician for coding responsibility.
• Current Certified Pharmacy Technician for pharmacy audit responsibility.
• 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.

Departmental Qualifications:

• Knowledge of Interqual criteria is preferred.