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Job DescriptionYour RoleThe Operations Audit Oversight team (within the Claims Organization) partners with external audit firms, regulators and internal partners to support required audits. The Experienced Compliance Audit Services Specialist will report to the Senior Manager of the Claims Partnerships and Communications team. In this role you will have the opportunity to work with a dynamic team auditing claims, investigating root cause, proactively auditing through data analysis as well as claims research, and support the Calpers Account.Your WorkIn this role, you will:• Conduct comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model and assure compliance to in-house and/or external specifications and standards• Be responsible for revision of policies and procedures to comply with regulatory changes and for training internal staff• Manage internal & external data reporting on compliance, interdepartmental performance reviews, and monthly claims delegation compliance reviews• Leverage your claims knowledge to initiate resolution at the root cause of issues and ensure avoidance of future issues• Have the ability to work with internal partners to facilitate issue resolution• Combine your passion for claims with your ability to identify larger scale claims issues with data analysis• Communicate with different audiences who may need various levels of information, and you will use your communication expertise to share information clearly• Be a critical member of a collaborative, fantastic teamQualificationsYour Knowledge and Experience• Requires a bachelor's degree or equivalent experience• Requires at least 3 years of prior relevant experience• Requires an analytical mindset, ability to determine root cause of a claims issue, as well as upstream and downstream impacts• Requires an agile attitude, ability to change directions and prioritization when needed• Requires excellent communication skills, and the ability to translate claims processing information / processing rules into language all can understand – inside and outside of this organization. Requires knowledge of MS Office Applications, and perform claims analysis in Excel. Preferred knowledge and/or ability to run reporting in Business Objects• Requires Facility and Professional claims processing knowledge and experience and the FACETS system.• Prefer candidates with knowledge of Self-Funded business; and will require a specific understanding of Calpers’ benefits and processing rulesPay Range:The pay range for this role is: $71,280.00 to $99,770.00for California.Note:Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.About The TeamBlue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California’s top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!Our Values:• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.• Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.Our Workplace Model:Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That’s why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.Two ways of working: Hybrid (our default) and office• Hybrid – In a business unit approved office a few times per year to 3 days per week, on average• Office – In a business unit approved office 4+ days a week, on average. If the role you’re applying for is deemed an “Essential Role,” the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.Physical Requirements:Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.Please click here for further physical requirement detail.Equal Employment Opportunity:External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.