Quality Auditor I-1

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years , we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

About the Role

Responsible for ensuring service operations compliance with product guidelines and conducting audits.

What You'll Do

Responsibilities:

• Performs statistically valid audits based on the BCBSA or Performance Guarantee, and other Horizon guidelines to determine the accuracy of responses to inquiries.

• May conduct trending: identifying top errors and improvements, identifying strengths, escalating areas of improvement and tracking best practices.

• Assist in maintaining keying guidelines and disseminate quality alerts used by vendor(s).

• Will assist in appeals process with multiple business partners by providing supporting information.

• Will act as coach for vendor samples and performance training.

• Documents identified defects to develop root cause and provide recommendations for process improvements or system enhancements for the overall improvement of accuracy efficiencies

• Maintains records of all source documentation reviewed. This includes but is not limited to electronic raw data, provider contracts, pricing information, and benefits.

• Provides support to operations staff.

• May use educational tools to address to improve overall accuracy.

• Review benefits against the original source document for validation.

• Conducts Focused Audits in support of management, customer, and Internal Audit department requests and provides feedback to reduce errors and improve processes and performance.

• May support enterprise wide projects by understanding the scope of the project, ensure timely and accurate project completion, will report findings to the appropriate personnel.

• Participate in regular internal /external meetings for purposes of calibrations, trends, best practice sharing, identify process improvements, and streamline processes.

• May be responsible for first draft review of audit points for focused audits such as PG and MTM.

• Perform other related tasks as assigned by management.

What You Bring

Education/Experience:

• High School Diploma/GED required.

• Minimum of three (3) years with a strong knowledge of processing experience preferred

• Minimum of two (2) of quality or audit or training experience

Knowledge:

• Requires expert level knowledge of multiple lines of claim processing systems and business

• Ability to interface with all levels of personnel, and external clientele

Skills and Abilities:

• Organization

• Multitasking

• Analytical Thinking

• Strong Interpersonal

• Presentation Skills

• Position may require bilingual skills (i.e. Spanish) for pre-determined lines of business / vendor partners.

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!

Salary Range:

$56,200 - $75,285

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

Disclaimer:

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

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