Position Description:

Capital Blue Cross has an exciting opportunity for a Performance Analyst to join our award-winning organization. Since 2014, Capital Blue Cross has scored higher than all health insurance providers publicly measured in the American Customer Satisfaction Index (ACSI) and is proud to be named a Best Places to work in PA, Harrisburg Magazine’s Simply the Best, and Highest Member Satisfaction J.D. Power Award.

This position is responsible for the audit functions related to determining and validating Plan performance, as it relates to Membership, Claims and Customer Service activity. This is accomplished through accordance with established policies, internal procedures and BCBSA mandated audit guidelines related to the following compliance programs MTM, FEP, LDLA and OPM-MSP. The position also provides analysis, reports and feedback as it relates to assigned Performance Guarantee Accounts, and participates in external Client audit requests.

Responsibilities and Qualifications:

Responsibilities:

• Audits claims, customer service inquiries, member and group enrollment activities, product builds as well as focus and client audits as assigned. 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 III for internal and BCBSA report compilation.
• Follows internal Gatekeeper processes for assigned Performance Guarantee accounts to assure accurate reporting of results.
• Participate in team collaborative efforts to resolve audit issues.
• Utilizes the internal Audit Database to communicate findings and follow up assuring corrective action is taken and documented.
• Completes the BCBSA LDLA Tool with the required information during LDLA reviews and provides completed work to the Reviewer for required review. Utilizes Reviewer feedback to assure independent compliance with the Program, identifying trends and assure ongoing accuracy.

Experience:

• A minimum of 5 years' experience in Claims, Membership or Customer Service (or combination of the three); depending on current business needs.
• Audit and/or Analytical experience desired.

Education and Certifications:

• High School diploma or GED.

Skills:

• Research, analytical and problem-solving skills.
• Ability to communicate effectively with diverse audiences both in writing and verbally.
• Ability to address workload to meet numerous deadlines, accommodate and adapt to changing priorities.

Knowledge:

• Understanding of the Healthcare industry as it relates to CBC
• Understanding of claims coding and processing including BlueCard and FEP; membership processes at both the group and member level; and customer service processes, also including FEP.
• Familiar with CBC’s various product designs and their coding structures.
• Familiar with Microsoft Office applications especially Excel.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must be able to work over 40 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds.!!Must be able to work in excess of 37.50 hours a week when necessary.

About Us: Capital Blue Cross is the leading health solutions and insurance company in Central Pennsylvania and the Lehigh Valley. As a partner in the community’s health for over 80 years, Capital Blue Cross offers employees excellent pay, bonus opportunities, benefits, health and wellness incentives, opportunities for career advancement and community involvement, and work-life balance. In return, every member of our workforce plays an important part in something much bigger: working together and making a difference every day to improve the health and well-being of our members and the communities in which they live.