Sr. Auditor chez Blue Cross Blue Shield of Michigan Mutual Insurance Company

Departmental Summary:

Responsible for analyzing and reviewing medical records and healthcare claims to ensure accuracy, and appropriate billing. Verify that patient care documented records is medically necessary and that codes used for billing are correct.

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.
• 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 Preference:

• Bachelor's degree in Nursing preferred.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.