Payment Policy Sr. Specialist

Blue Cross Blue Shield of Massachusetts • Boston, MA

21d

About The Position

Ready to help us transform healthcare? Bring your true colors to blue. 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. Key Functions: 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

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

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

Benefits

• We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees