Provider Education Program Manager - Payment Integrity

Blue Shield of North Carolina • Durham, NC

9d • Hybrid

About The Position

The Provider Education Program Manager is responsible for designing, implementing, and managing a health plan provider education program focused on identifying and addressing billing patterns indicative of potential upcoding, documentation variance, and other provider billing outliers. This role uses claims, coding, and reimbursement data to identify providers with aberrant billing patterns; develops and distributes provider education letters; conducts outreach and follow-up calls; performs quarterly and semiannual monitoring to assess behavior change; and partners with Payment Integrity, Provider Relations, Compliance, and Special Investigations Unit (SIU) teams to escalate cases when educational intervention does not result in sustained improvement.

Requirements

• Bachelor's degree or advanced degree (where required)
• 8+ years of experience in related field. In lieu of degree, 10+ years of experience in related field.
• CPC, CCS (Required), CEMA, CPMA (Strongly Preferred), CPIP (Nice to have) or similar coding/compliance certification.
• Experience in managed care, Medicare, Medicaid, Marketplace, or commercial health plan operations.
• Experience with provider education, payment integrity vendor outputs, post-pay review, overpayment recovery, or FWA/SIU workflows.
• Advanced Excel, dashboarding, and data visualization skills.
• Strong knowledge of CPT, HCPCS, ICD-10, modifiers, documentation standards, reimbursement methodology, CMS guidance, and payer billing requirements.

Nice To Haves

• CPIP or similar coding/compliance certification

Responsibilities

• Develop and maintain the health plan’s provider education program for coding, documentation, and billing integrity issues, with a focus on potential upcoding and other aberrant provider billing patterns.
• Establish program workflows, referral criteria, outreach templates, monitoring schedules, escalation pathways, and reporting standards to support compliant and consistent operations.
• Create standardized processes for provider identification, educational intervention, follow-up review, and referral to SIU when concerning behavior persists.
• Analyze claims, coding, utilization, reimbursement, and provider billing data to identify outlier patterns, unusual coding distributions, trending variances, and potential upcoding concerns.
• Conduct targeted reviews using CPT, HCPCS, ICD-10, modifier usage, and documentation-related indicators to determine whether provider billing patterns warrant education or further escalation.
• Partner with payment integrity, analytics, and coding subject matter experts to validate findings, quantify impact, and prioritize outreach opportunities.
• Draft and issue provider education letters that clearly describe identified billing concerns, applicable coding/documentation expectations, and recommended corrective actions.
• Conduct provider outreach calls and meetings to review findings, explain coding or documentation expectations, answer questions, and reinforce compliant billing practices.
• Develop educational materials, job aids, presentations, and provider-specific feedback to support improved coding accuracy and billing compliance.
• Perform quarterly and semiannual post-education monitoring to assess whether provider billing behavior changes after outreach and whether additional intervention is needed.
• Document measurable outcomes such as coding trend shifts, reduction in outlier behavior, education completion, and cases escalated for further review.
• Develop and administer a formal referral process to SIU for providers whose billing patterns do not improve following education or whose behavior suggests potential fraud, waste, or abuse.
• Prepare referral summaries, supporting documentation, trend analyses, and case narratives for submission to SIU, Compliance, or legal/regulatory partners as appropriate.

Benefits

• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match including an annual company contribution

What This Job Offers

• Job Type: Full-time
• Career Level: Senior