Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

Responsible for planning, executing, and reporting provider and financial claim audits for the Government Program division as necessary to comply with the NJ Medicaid contract. The incumbent in this role will act as a SME in developing the audit scope and work programs, executing the audit identifying issues and root cause, providing recommendations for corrective actions, and reporting findings.

• Perform various analyses and audits relating to Medicaid/Medicare/Managed Care engagements.
• Prepare reports and may assist in presenting reports to senior management for State reporting.
• Accountable for identifying and assessing provider and claim audit processes and/or transactions including, but not limited to the completeness and accuracy of financial information and transactions, compliance with applicable laws and regulations, and the effectiveness and efficiency of operations.
• Perform risk assessment, audit planning, including determine appropriate audit period and scope of audit.
• Conduct all phases of the audit, including, fieldwork, analyze/review data, reporting of findings, making recommendations for improvement and other procedures as required.
• Conduct trend analysis; identifying top errors and improvements, identifying strengths, escalating areas of improvement and tracking best practices.
• Evaluate accuracy and effectiveness of Operations administration of benefits on all claim systems and lines of business.
• Assist/support in Government Programs enterprise-wide projects. Identify the scope of the project, assign auditors, ensure project completion is timely and accurate; and ensure that reports go to the appropriate personnel.
• Participate in internal/external meetings for purposes of calibrations, trends, best practice sharing, identify process improvements, and streamline benefit/reimbursement processes.
• Train, coach, and serve as a resource for junior staff members.
• Perform assessments on quality audits: perform quality audits on less seasoned auditors (function as a work leader).
• The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position.
• This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.

Education/Experience:

• Minimum high school diploma or GED

• Bachelors degree preferred from an accredited college or university, preferably in Finance, Business Administration, or related field or equivalent work experience.

• FACETS experience highly preferred.

• Requires 2 - 4 years of relevant audit experience preferred (public accounting and/or internal audit).

• Experience in healthcare financial management, auditing and data analysis preferred.

Additional licensing, certifications, registrations:

• CPA, CPA candidate, CIA, CIA candidate, or CFE preferred.

Knowledge:

• Preferred knowledge of Microsoft Office software.

• SAS or SQL programming skills a plus but not required.

• Requires knowledge of general accounting principles and methods; prefer knowledge of both Generally Accepted Accounting Principles (GAAP) and Statutory Accounting principles (SAP).

• Experience in hospital or health insurance auditing and data analysis.

• Familiarity with healthcare provider reimbursement methodologies and coding standards

Skills and Abilities:

• Requires good oral and written communication skills.

• Strong analytical and problem solving skills.

• PC skills including Excel, Access and Microsoft Office Suite of products required.

• Requires strong analytical skills including the ability to research and resolve problems, report findings accurately, identify solutions and implement resolutions through interaction with companywide personnel.

• Requires the ability to plan, organize and prioritize work assignments, and handle multiple tasks.

• Requires the ability to work independently and exercise sound business judgment.

• Requires proficiently in planning and organization.

• Requires solid skills in MS Office applications (particularly Excel and Access).

Salary Range:

$76,800 - $102,795

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.