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Position Description
Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market-driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
At Capital Blue Cross , we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”
This position serves as a subject matter expert and liaison between Capital Blue Cross (Capital) internal business units, external auditors, and regulatory agencies. This role ensures successful execution of external audits, response oversight, and compliance with Capital processes and standards. The position requires deep knowledge of Capital organizational structure, claims processing systems, and operational workflows. The incumbent will independently manage complex projects, interact with senior leadership, and maintain accountability for audit deliverables and reporting.
Responsibilities and Qualifications
Plan, organize, and lead external audit projects related to group benefit examinations and other group audits allowed by the contract, BCBSA audits, and contractual compliance reviews.
Act as primary liaison between external auditors and Capital operational areas on all aspects of external audits.
Track and manage audit deliverables, ensuring timely completion and accurate documentation.
Provide training to internal parties for appropriate support in engaging with external auditors and reviewing noted audit exceptions.
Recommend and develop department policy and procedures.
Provide leadership to ensure Capital meets its contractual obligations with respect to existing group audit rights and compliance clauses.
Review and coordinate with Legal on proposed changes to contractual audit rights and advise Sales and Underwriting Management on prospective changes.
Maintain strong, collaborative relationships with external auditors and ensure adherence to Capital standards.
Lead internal meetings, including Senior Leadership, to discuss audit-related matters.
Demonstrate knowledge of Capital processing systems, including Pharmacy (Rx) workflows.
Provide guidance on Capital processes and organizational structure to internal and external stakeholders.
Oversee, coordinate, and schedule external audits, examinations, or surveys. This includes, but is not limited to, maintaining an appropriate external audit schedule balanced with existing resources, collecting and maintaining all requested documentation in compliance with Capital standards, ensuring timely completion of all external audits, and adequate/timely/professional responses from internal stakeholders.
Monitor open and closed audit items, assign tasks, and ensure timely follow-up.
Recommend corrective actions to operational functions and verify implementation through performance tracking.
Communicate effectively with Capital leadership, providing updates on audit progress and compliance risks.
Prepare and present reports for management review.
Skills:
Deep understanding of Capital systems and processes.
Strong negotiation skills.
Proficient in Microsoft Office Suite and audit tracking tools, combined with analytical and problem-solving skills.
Exceptional organizational and project management skills. Experience in planning, organizing, and managing complex cases or initiatives.
Ability to influence and communicate effectively through written and oral communications across all levels of the organization, external auditors and account representatives, with a focus on communicating complex issues in an organized concise manner.
Ability to establish and maintain cooperative and professional working relationships across multiple departments within Capital.
Ability to adjust to changing priorities and manage time effectively to meet urgent deadlines.
Knowledge:
Knowledge of Capital commercial, ancillary, and government product lines and all supporting operations sold/serviced by Capital and its associated business ventures.
Working knowledge of departments and administrative procedures in sales, marketing, enrollment, billing, underwriting, configuration, IT, claims, customer service, clinical management, government programs, internal audit and finance processes, preferably in the health insurance industry.
Familiarity with operational processing systems utilized throughout Capital’s business operations, such as MARIS, Salesforce, and FACETS.
Experience:
5 years' experience in compliance/audit.
Project management experience required.
Experience in health care administration, claims processing, pharmacy operations preferred.
Education and Certifications:
Bachelor’s degree in accounting, finance, business, or data analytics, or the equivalent of 8 or more years in project management and/or audit experience required.
Advanced degree preferred.
Certifications preferred: Certified Quality Auditor (CQA), Certified Internal Auditor (CIA), Certified Information Systems Auditor (CISA), Certified Public Accountant (CPA), Certified Risk Management Assurance (CRMA), Certified Analytics Professional (CAP).
About Us
We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live. Originally posted on Himalayas
