• Audits FEP claims, customer service inquiries, member and group enrollment activities in accordance with Plan Incentive Program (PIP) guidelines • Completing Performance Guarantee audits • Supports IA and SIU with assistance as needed • Utilizing internal formatting, maintains adequate documentation to support all audit reviews and outcomes • Providing this material to the appropriate Performance Analyst for internal and BCBSA report compilation • Participate in team collaborative efforts to resolve audit issues • Utilizes the internal SharePoint Audit tool to communicate findings and follow up assuring corrective action is taken and documented

• Analyze data to assist in the design of our Value Based Programs (VBP) - including accountable care arrangements, medical neighborhoods, and other value-based Initiatives. • Work with senior business analyst to develop analytic and/or report requirements that support their ability to make informed decisions regarding strategy initiatives/objectives, and/or appropriate tactical level actions. • Work within the Network Analytics and Pricing (NAP) Unit to help identify, research, and resolve operational and other business issues relating to the value-based programs and initiatives. • Intake queries from physician practices related to reports and process flows associated with VBP and initiatives (i.e., provide first line of support), refine requirements and coordinate responses from informatics and reporting resources. • In collaboration with informatics and reporting functional areas and information technology experts, assist in establishing self-service tool requirements that allow for the efficient production of reports and analyses. • Develop an understanding of various company information assets to leverage for use in the VBP activities. • Research and understand industry best practices in payment reform and accountable care organizations pilots/initiatives that are being undertaken by other health plans.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Serves as an entry level professional who develops baseline plans for ensuring the integrity and accuracy of claims processes and protocols. Collects data for audits/investigations into claims, utilizing a combination of analytical skills and attention to detail, reviewing documentation, interviewing involved parties, and communicating with various stakeholders to gather relevant information for successful resolution and closure. Identifies opportunities to target fraud, waste, and abuse or discrepancies in claims submissions. Adheres to industry regulations and company policies for managerial follow-up. Analyzes data in order to effectively assess the validity of claims. Provides accurate recommendations to management for claim resolution and closure. Documents and inputs all findings, while preparing comprehensive reports that may be used for legal or audit/investigative purposes. Essential Duties and Responsibilities - Conducts routine and impartial audits/investigations into customer claims, ensuring accurate and fair assessments of claims validity. - Provides customer service by addressing inquiries and concerns, and escalates audit/investigation, as needed. - Compiles detailed and organized records of audit/investigation findings, ensuring accuracy and compliance with legal and regulatory requirements. - Applies functional knowledge to create and implement strategies to identify and prevent fraudulent activities, safeguarding the integrity of the claims process. - Conducts interviews with relevant witnesses, claimants, and other stakeholders to gather additional information and perspectives on claims. - Communicates with appropriate internal teams to ensure the proper processing of audits/investigations, while adhering to legal and regulatory standards. - Ensures that all audit and investigative documents and records are processed into the database in a timely and accurate manner. - Communicates audit/investigation findings clearly and professionally to customers, claimants, and other stakeholders, managing expectations and providing updates. - Supports management in regular audit and investigation proceedings, ensuring full compliance with all applicable regional and federal standards, regulations, and protocols. Qualifications - Minimum Bachelor's Degree - Prior experience in healthcare fraud investigation Preferred Skills/Experience - Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator - Prior successful experience with CMS and OIG/FBI or similar agencies - Medicare investigation experience a plus

• Play a key role in the assessment and fulfillment of clinical and operational reporting requirements mandated by accreditors;• Participate in the preparation and submission of applications related to accreditation access on behalf of Shields partners;• Conduct primary and secondary research in support of data needs for the accreditation process; with a focus on URAC and ACHC specialty pharmacy standards;• Aggregation of data for Quality Management Committees and Quality Management Program activities such as Quality Improvement Projects (QIPs) and collection of Performance Indicator (PI) data, using a variety of software, system reports, and other tools;• Analyze and prepare data, including recognizing discrepancies, errors, duplications, etc.;• Support workstreams related to accreditation data aggregation for QMC meeting minutes and any other requested data needs;• Independently manage data from numerous workstreams related to accreditation purposes;• Assist Accreditation teammates in providing exceptional and timely customer service to our partners on all matters related to accreditation data;• Identify solutions to non-standard requests and problems;