Payment Policy Sr. Specialist

BlueCross and BlueShield of Massachusetts•Boston, MA

70d

About The Position

Reporting to the Director of Professional Reimbursement Strategy, the Payment Integrity Consultant uses industry knowledge, research skills, payment policy and business operations knowledge to become a trusted subject matter expert on professional 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
Proficiency in working with and analyzing claims data
Strong written and verbal communication skills
Knowledge of CPT/HCPCS & ICD10 coding, Correct Coding Initiatives and CMS 1500 billing
Strong critical thinking & problem-solving skills
Ability to manage competing priorities
Experience in working with claims editing software
High school degree or equivalent required unless otherwise noted above

Nice To Haves

Certified Professional Coder (CPC) and certified outpatient coder (COC) preferred

Responsibilities

Support implementation of identified opportunities to improve the effectiveness of the Professional reimbursement strategy,
Assist managing provider reimbursement strategic planning process
Support the professional reimbursement strategic planning process and strategy execution, including gathering, analyzing, and prioritizing development needs and requirements
Participate in professional 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 claim editing logic and maintenance of existing 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 provider reimbursement methodologies, to support organizational efforts around improved quality, trend management, and payment reform activities.
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 reimbursement mailbox
Maintain and update the professional fee schedule 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