External Audit Facilitator

Location: This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.

The External Audit Facilitator is responsible for managing the process for claims and customer service audits/quality control reviews, including implementation audits, for National and Large Local Accounts and/or their representatives as well as the Blue Cross Blue Shield Association (BCBSA) and state regulatory examinations.

How You Will Make an Impact

Primary duties may include, but are not limited to:

• Manages multiple audits simultaneously.
• Independently develops and executes work plans, identifies resources, assigns individual responsibilities, and manages day-to-day operational aspects of each audit.
• Coordinating and facilitating audit team roles, responsibilities, and audit schedule.
• Reviews, negotiates, and approves scope presented by external auditor.
• For implementation audits, ensures the claims system is coded accurately by independently developing and running test claims, analyzing results, identifying and resolving client intent or benefit coding issues, proposing solutions and directing the implementation of changes.
• Develops and leads audit presentations.
• Applies audit policy, assesses risks to minimize company exposure and mitigate those risks.
• Works closely with the business to provide consultation and advice to management related to claim processing policy and procedure and investigates, develops and recommends process improvements and solutions.
• Develops and releases corporate response to audit findings to the external customer.
• Assist with communicating audit findings and recommendations to internal business owners, external customers and auditors.
• Partners with account management in discussing audit findings and recommended solutions with the customer, gains consensus and ensures solutions are implemented.
• Identifies key success factors and non-beneficial factors to be avoided in the future.

Minimum Requirements:

Requires H.S. diploma or equivalent and minimum 2 years internal claims processing (adjustments) experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Knowledge of multiple lines of business, plans and systems is strongly preferred.
• ITS Blue Card Processing experience preferred
• Payment integrity data mining experience preferred
• BA/BS degree preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.