Clinical Auditor

Department Overview

The Health and Clinical Engagement division provides valuable health and wellness services to help people maximize their health and quality of life. Health Management is one of the most critical issues Blue Cross and Blue Shield of Alabama faces in fulfilling its responsibility to be a superior administrator of health care benefits. Our goal is to provide the highest quality benefits and services while we effectively control health care costs.

This position is accountable for developing, coordinating and administering activities related to the review of the Concurrent Utilization Review Program (CURP), including auditing of utilization activities. Activities involve data analysis, information gathering and dissemination, conducting reviews of participating providers for quality care, resource utilization, and compliance with program directives. Participation in National Committee for Quality Assurance (NCQA) standards, continuous review of utilization standards, and interactions with diverse areas within the Corporation are important to ensure a consistent review process.

Effective communication with all members of the health care delivery system and Corporate system is essential.

• Bachelor of Science degree in Health or Business related field; or commit to actively pursue such a degree upon hire
• Active license as a Registered Nurse (RN)
• Multi-State Licensure as a Registered Nurse allowing practice in the State of Alabama or a State of Alabama licensure as a Registered Nurse
• Minimum three years of clinical experience as a Registered Nurse (RN)
• Experience in a position interacting with health care providers, executives, associates and managers
• Experience analyzing clinical situations and making informed decisions
• Experience in a position interpreting and communicating information orally and written
• Experience in a position resolving difficult and stressful situations
• Willingness to travel up to 25% of the time
• Knowledge of claims payment guidelines, billing guidelines, laws, and contracts that govern the health insurance programs administered by Blue Cross Blue Shield of Alabama preferred
• Experience using Microsoft Excel for mathematical computations and data analysis preferred
• Experience teaching or conducting training preferred
• Experience using and implementing Performance Management strategies preferred
• Experience applying Inter Qual acute care criteria preferred
• Experience in Utilization Management preferred

The work schedule for this position will be full time remote. Business areas reserve the right to require associates to return to the office as needed, based on performance or other business considerations. A remote work schedule is subject to amendment or termination at any time by the Company.

By submitting a job application, I attest that all information to the best of my knowledge is true and accurate. Furthermore, I understand that any information provided by me throughout the job application process is subject to verification including, but not limited to work experience, education, assessment (test) and interviews.

We appreciate your interest in Blue Cross and Blue Shield of Alabama 'The Company'. The Company does not discriminate in hiring or employment on the basis of race, color, religion, creed, sex, sexual orientation, gender identity, national origin, age, disability, genetics, status as a disabled or protected veteran, or because of citizenship status in the case of a citizen or intending citizen.

No question on this application is intended to secure information to be used for such discrimination.

Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association.