Quality Control Auditor

About The Role
The Quality Control Auditor, objectively, systematically, and continuously assesses, assures monitors, evaluates, and improves the quality of processes and services provided based on BHPS’s commitment to client satisfaction and continuous improvement.

Primary Responsibilities

• Performing routine and complex audits for all operational staff including but not limited to enrollments & maintenance, claims adjudication & adjustments, member & provider data integrity in the claim, pre-certification calls & customer service calls evaluations.
• Developing, preparing and reporting results of special projects assigned in a timely and efficient manner
• Assisting in identifying the root cause of errors inline to system configuration vs manual processing
• Providing information to the quality management leadership team regarding need for group and/or individual training based on audits
• Performing focus audits for claims examiners and client service supervisors

Essential Qualifications

• High School or Diploma
• Minimum 3 years in auditing of claims adjudication or customer service calls evaluation
• Experience or knowledge of Blue Cross Programs is added advantage.
• Working knowledge of medical terminologies and coding considered to be added advantage.
• MS Office Suite applications, including but not limited to: Word, Excel, Outlook, PowerPoint
• Strong analytical aptitudes, communication, and comprehension capabilities.

* General Knowledge of HIPAA Confidentiality Laws

About
At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.
Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.
Come be a part of the Brightest Ideas in Healthcare™.

Company Mission
Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision
Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

DEI Purpose Statement
At BHPS, we encourage all team members to bring your authentic selves to work with all your unique abilities. We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace. We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.
*We are an Equal Opportunity Employer