Claims Auditor

Performance Auditor (Open to hiring at level I or II) Full-time Department: Legal | Compliance | Audit | Risk Pay Grade: 17 Why Wellmark : We are a mutual insurance company owned by our policy holders across Iowa and South Dakota, and we’ve built our reputation on over 80 years’ worth of trust. We are not motivated by profits. We are motivated by the well-being of our friends, family, and neighbors–our members. If you’re passionate about joining an organization working hard to put its members first, to provide best-in-class service, and one that is committed to sustainability and innovation, consider applying today! Learn more about our unique benefit offeringshere . As a Performance Auditor, you will play a crucial role in ensuring the integrity and efficiency of Wellmark’s core business processes. Your responsibilities will include conducting Blue Cross Blue Shield Association validation audits of claims payments, member benefits and enrollment, customer service inquiries, and provider contracts. You will leverage your expertise to analyze and improve financially and operationally significant corporate functions and transactional data, contributing to the overall success and compliance of the organization.As a Performance Auditor II, you will also compile and present reports to operational stakeholders and collaborate closely with business leaders to develop and monitor effective corrective action plans. If you possess strong data literacyand caninterpret complex information to uncover insights, identify patterns, and recommend improvements, this role may be a fit for you. As Wellmark continues to evolve, you’ll apply your technical aptitude and adaptability to navigate changing systems, tools, and processes effectively. Ideal candidates will have a bachelor's degree and prior experience in finance, business, or related fields. To be successful in this role, you will be detail-oriented and have the communication skills to build strong relationships with peers and stakeholders. Coworkers and friends would say you are able to identify issues or inconsistencies easily, with the ability to summarize findings and develop action plans accordingly. You are thorough, deadline-driven, and leave no stone unturned. Performance Auditor I Required: Bachelor’s degree or equivalent work experience. Prior experience in a Finance/ Accounting/ Auditing/ Business related field OR demonstrated experience in understanding health insurance such as knowledge in claims processing, membership and enrollment, customer service, etc. Analytical abilities and attention to detail; including following, documenting and identifying improvements in processes and procedures while maintaining awareness of rules, regulations, and interdependencies. Ability to identify issues or inconsistencies using strong business knowledge and perspectives and see issues through to finalization. Strong attention to detail, with the ability to learn, retain, understand and apply general insurance and audit concepts to ensure tasks are completed accurately. Effective communication skills, both verbal and written. Ability to build and sustain relationships through successful collaboration skills. Demonstrated ability to use deductive reasoning to probe, research, ask questions, seek to understand; weighs alternative actions and makes decisions that incorporate data, and facts. Proficiency in the use of corporate computer systems, programs, and software applications. Exhibits an eagerness to learn and stay current on industry and technology trends. Flexible and adaptable to changing priorities. Preferred: Audit or health insurancecertificationsuch as CIA, CFE, IAP, CPC, CCS, or CPMA. Performance Auditor II Required: Bachelor’s degree in accounting or related field, or equivalent work experience. Minimum 1 year of internal or external audit experience or minimum 2 years of quality assurance experience. Minimum 1 year of health insurance experience. Demonstrated proficiency across one or more core business processes, including BCBSA standards and regulatory requirements. Proven analytical skills, with the ability to analyze data, and support the identification of trends. Strong communication skills, both verbal and written. Proven ability to work independently and ensure that audits are conducted completely and accurately. Preferred: Audit experience in the Insurance industry. Audit or health insurance certification such as CIA, CFE, IAP, CPC, CCS, or CPMA. Ensure compliance with the Blue Cross Blue Shield Association’s (BCBSA) mandated standards and regulatory requirements through comprehensive validation audits of core operational processes. These include but are not limited to reviewing claims accuracy, provider data adherence, enrollment and benefit integrity, customer service accuracy, and plan to plan communication integrity. Develop expertise in one or more core business processes, including BCBSA standards and regulatory requirements, while gaining broad exposure to other key functions to support audit and compliance activities. Conduct operational performance guarantee validation audits of core business processes using statistical sampling methodologies in accordance with contractual requirements. Performs audit projects as assigned, including correctly identifying issues and coordinates corrective action plans in accordance with regulatory and BCBSA guidance. Assist with reviewing populations of transactional data against established parameters for accuracy and completeness. Develop and document samples to be audited in accordance with audit requirements. #J-18808-Ljbffr