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Manager of Audit and Quality - Federal Employee Program

Hingham, MA

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Manager of Audit and Quality - Federal Employee Program
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The Audit and Quality Manager is responsible for leading a team of auditors, analysts, quality coaches, documentation specialists and a senior analyst. This position is responsible for the oversight of all external claim and process audits, plan self-assessments and questionnaires as well as other auditing entities. In addition, the manager is responsible for Audit and Risk Management (ARM) and Plan audits specific to FEP operational areas and Office of Personnel Management Appeals.
Key Accountabilities:
Ensure all external audits, questionnaires, and plan self-assessments as issued are completed in a comprehensive and timely manner.
Provide primary on-site support to external auditors
Maintain compliance with all operational aspects of Federal CS1039 contract
Identify red flags and take immediate action to mitigate risks on all audit activity, internal or external
Ensure all Appeals are completed accurately and returned to OPM within required timeframes
Identify and conduct targeted internal claims reviews and process audits to mitigate risk and improve operational efficiencies
Oversee the quality excellence program for claims, member and provider calls and correspondence, enrollment, post service review and reconsiderations to ensure accuracy of information and processing. Trend outcomes and identify opportunities for improved performance development as well as member and provider satisfaction.
Key contributor to achieving financial success by meeting or exceeding the FEP Plan Incentive Program measures specific to Customer Experience and Transactional Index. The program is administered and awarded by the FEP Director’s Office to plan’s reaching excellence status.
Drive changes that influence member satisfaction measures such as First Call Resolution and claims accuracy as captured through SQM and CAHPS results
Lead or actively participate in key projects related to new initiatives or complex business challenges
Through root cause analysis, identify and recommend systematic/manual solutions to resolve workflow/operational issues that drive efficiencies and lower cost
Direct management of internal communication and documentation impacting all operational functions including service, claims, enrollment, reconsiderations and clinical review. This includes all directives and government mandates as specified by the FEP Director’s Office (BCBSA) as well as the FEP Operation’s Center.
Continuously gain in-depth understanding of processes in order to independently develop clear and concise end-user documentation
Represent FEP on several provider/Plan sessions and ensure all provider communications accurately represent program expectations
Oversee compliance activities, such as provider terminations, debarred providers, fraud waste and abuse trainings, and various other mandates to adhere to the rules and regulations set forth by the Federal Government.
Work cross-functionally to facilitate and organize actions that meet FEP, Division and Corporate goals
Challenges/Problem Solving:
Level of high visibility within the government sector
Government audits can be large in scope and frequency and span several years of claim processing and administrative activity to identify instances where obligations were violated based upon contractual requirements.
Successful completion of high volume, complex audits with stringent deliverable dates established by outside entities
Proper delegation of tasks to meet all requirements due on or around the same timeframes
Dual system claims processing platforms
Federal Account with unique rules and regulations
Managing concurrent internal critical projects with competing priorities and aggressive deadlines
Maximize potential earnings through the Plan Incentive Program
Aggressive deliverable dates mandated by the FEPDO and FEPOC
Proactively work with Business Partners to increase level of FEP understanding that impact program performance and goals
Decision Making Authority:
Ability to develop and execute strategies
Takes appropriate action for resolution to audit findings and standard/complex business issues
Collaborate and influence others outside the business unit to resolve claims issues (such as Audit and Controls and the FEP Director’s Office)
Provide direction to staff to ensure business plan and team goals are achieved or exceeded
Leadership Qualifications:
Strong analytical skills; ability to identify/resolve problems and implement risk management safeguards
Lead innovative, analytical thinking with root cause analysis. Challenge others to seek opportunities for improved operational efficiencies that positively impact our overall service score, enhance and develop the skills of associates, and lead to member and provider satisfaction.
Ability to manage multiple, complex projects with competing and aggressive timelines to meet mandates, operational, service, and financial goals
Develop solutions to highly complex business issues affecting BCBSMA FEP members or providers; document and communicate resolution across all areas.
Foster an environment that promotes ownership, results, teamwork, loyalty and growth opportunities
Represent and support senior director by completing special projects as assigned
Strong interpersonal skills, operations management and communications
Strong knowledge of current technologies, applications and communication channels
Demonstrate success in process and quality improvements
Build and maintain solid network with external partners (FEP Director’s Office, FEP Operations Center, OPM) as well as internal areas, such as finance and ARM
Business travel as required
Education/Relevant Experience:
3-5 years successful audit and quality related experience
3-5 years of relevant leadership experience
Experience managing cross-functional teams and projects
Bachelor’s degree or equivalent professional experience required
LocationHinghamTime TypeFull time
Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.
Our Commitment to You
We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.
Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.
Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.
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