Senior Strategic Advisor, Healthcare

Blue Cross and Blue Shield of North Carolina

21h•Hybrid

About The Position

Blue Cross NC Medicare is a high-performing Medicare Services Organization (MSO) supporting North Carolina Medicare Advantage members operating under full-risk value-based care arrangements. As a fully delegated MSO, BCBSNC assumes accountability for claims adjudication, provider payment, and regulatory CMS compliance on behalf of partner health plans and providers. The Sr. Strategic Advisor, Medicare Payment & Reimbursement Policy Advisor serves as a senior individual contributor and subject matter expert supporting the interpretation, application, and operational alignment of Medicare payment and reimbursement policies. This role serves as a liaison between Segment, Clinical Policy, Product, Network, and Operations including claim processing, capitation and value-based arrangements, and administration of product design. The position operates collaboratively across Claims, Provider Configuration, Finance, Compliance, IT, and Health Plan partners, contributing to consistency, audit preparedness, and payment accuracy, while working within established governance and operational structures. From a CMS and delegation perspective, this role functions as: A key advisor supporting translation of regulation into payment operations A contributor to policy validation and audit readiness efforts A subject matter resource helping prevent inconsistencies in reimbursement application. The Sr. Strategic Advisor does not own compliance, claims operations, or enterprise governance, but plays a critical role in supporting correctness, defensibility, and consistency of Medicare payment outcomes through expert analysis and advisory partnership.

Requirements

Bachelor’s degree in Healthcare Administration, Business, Finance, or related field
5 years of relevant experience
Medicare Advantage experience with exposure to reimbursement, claims payment, or payment policy
Strong working knowledge of CMS Medicare Advantage payment regulations
Experience operating in a matrixed or shared-services environment
Understanding of claims adjudication logic, provider payment methodologies, and claims platforms (e.g., FACETS)

Nice To Haves

Master’s degree (MBA, MHA, or related)
Experience supporting CMS audits, payment integrity initiatives, or regulatory reviews
Familiarity with configuration tools and reimbursement analytics
Exposure to multiple MA products (MA, D-SNP, PDP)

Responsibilities

Medicare Advantage payment and reimbursement policy interpretation.
Collaboration with compliance and operations in the evaluation and application of CMS guidance via HPMS Memos and HLN Bulletins.
A Clinical or payment policy approval, validation support, and risk identification.
Translation of policy requirements into operational guidance Medicare requirements for product, clinical policy or payment policy.
Regulatory and delegation compliance support.
Strategic advisory input on reimbursement risk and implication.
Serve as a senior subject matter expert on Medicare Advantage payment, reimbursement, and claims-related CMS policy.
Interpret and evaluate CMS guidance, health plan reimbursement direction, delegation requirements, and contractual payment terms.
Assess the operational and compliance implications of new or updated CMS guidance, health plan bulletins, and MLN updates.
Provide advisory input to leadership on reimbursement-related risks, ambiguities, and potential financial impacts.
Support periodic reviews of Medicare payment and reimbursement application across claims adjudication and provider payment processes.
Assist in validating that claims logic and provider payment processes align with CMS and health plan requirements.
Identify and escalate potential policy misinterpretation, inconsistent application, or configuration gaps that could lead to payment variance or compliance risk.
Partner with Finance, Actuarial, and Compliance teams to support payment integrity reviews, reconciliations, and remediation activities.
Collaborate with Claims Operations and Provider Configuration teams to translate Medicare reimbursement policy into clear operational guidance, including system, configuration or process requirements: Claims adjudication considerations, Provider configuration standards, Fee schedules and payment methodologies.
Develop and maintain documentation connecting regulatory policy language to operational execution to reduce interpretation risk.
Participate as a subject matter advisor in configuration and adjudication discussions to support reimbursement accuracy and policy alignment.
Review proposed configuration or process changes driven by CMS guidance, health plan updates, or contractual changes for consistency with policy intent.
Support root-cause analysis of claims issues where reimbursement outcomes signal potential policy or configuration concerns.
Partner with Compliance and operational teams in preparation for CMS audits, health plan delegation audits, and internal reviews.
Support documentation and evidence development related to Medicare reimbursement policy application.
Assist with reimbursement-related corrective action planning by providing policy interpretation and operational alignment guidance.
Provide strategic input to Medicare leadership on reimbursement-related risks, trends, and regulatory considerations.
Educate operational partners on Medicare reimbursement policy impacts in a practical, execution-focused manner.
Serve as a trusted advisor during periods of regulatory change, system updates, or audit activity.