Payment Policy Sr. Specialist

Blue Cross Blue Shield of Massachusetts • Hingham, MA

94d • $87,930 - $107,470

About The Position

Ready to help us transform healthcare? Bring your true colors to blue. Reporting to the Payment Integrity Program Manager, the Payment Integrity Consultant uses industry knowledge, research skills, payment policy and business operations knowledge to become a trusted subject matter expert on facility payments. Excelling at this work as part of a small but mighty team, is critical to BCBSMA’s goal of affordability.

Requirements

• Bachelor’s degree or equivalent experience or training
• 5+ years relevant healthcare industry experience
• Strong understanding of healthcare reimbursement methodologies
• Certified Professional Coder (CPC) and certified outpatient coder (COC) preferred
• Proficiency in working with and analyzing claims data
• Strong written and verbal communication skills
• Knowledge of CPT/HCPCS & ICD10 coding, Correct Coding Initiatives and UB04 billing
• Strong critical thinking & problem-solving skills
• Ability to manage competing priorities
• Experience in working with claims editing software

Responsibilities

• Support implementation of identified opportunities to improve the effectiveness of the facility reimbursement strategy
• Assist managing provider reimbursement strategic planning process
• Support the facility reimbursement strategic planning process and strategy execution, including gathering, analyzing, and prioritizing development needs and requirements
• Participate in facility reimbursement payment integrity activities that include developing new payment policies, revising existing payment policies to align with intended payment practice, draft proposals, assessing operational impacts, inquiries and implementation efforts
• Assist in developing new facility claim editing logic and maintenance of existing facility rule logic to support payment integrity efforts and existing reimbursement guidelines
• Support the development and implementation of reimbursement strategies for the successful modification and implementation of institutional provider reimbursement methodologies
• Manage and expand pre-payment integrity programs
• Identify new Payment Integrity vendors as needed, negotiate contractual terms and manage the relationships
• Manage and respond to inquiries within the facility reimbursement mailbox
• Maintain and update the hospital outpatient and drug fee schedules, including assessing and pricing new codes
• Analyze claims data in conjunction with provider reimbursement methodologies and external benchmarks to assess financial impacts that will help inform payment integrity improvement opportunities and decisions
• Evaluate opportunities and translate those needs into project requirements and activities for business and/or IT to address
• Deliver business requirements to address payment policy updates and/or reimbursement updates
• Other duties as assigned

Benefits

• Paid time off
• Medical/dental/vision insurance
• 401(k)
• Suite of well-being benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees