Sr Dir, Enterprise/Blue-Blue Payment Integrity

Horizon Blue Cross Blue Shield of New Jersey•Newark, NJ

20h•Hybrid

About The Position

As leading enterprise subject matter expert on Payment Integrity (PI) that is accountable for driving ~90% of Horizon PI savings, this position has enterprise wide responsibility for developing, maintaining and executing on the company’s Payment Integrity Program strategy. This entails sustaining annual savings of approximately $600M while optimizing capabilities to achieve a year over year savings increase of approximately $25M. To achieve these outcomes requires collaboration with senior leaders across the organization. The position provides direct leadership for five distinct PI teams within Health and Network Solutions (HNS) comprised of ~50 Horizon employees and dedicated vendor staffing of approximately 100 FTE with an annual budget in excess of $45M (inclusive of ~$37 M in vendor costs). The teams have direct line accountability for the Enterprise’s Primary and Secondary Code Editor; multiple internal and vendor sourced Outlier Audit Programs; Contract Compliance, DRG, Outpatient and Credit Balance Audits; PI Parity Billing & Invoicing and several Prepayment PI programs each supporting our fully insured lines of business across our Commercial and Government sector and others supporting all lines of business including our ASO clients. The responsibilities of the position are grouped into the below 3 areas: 1) Leadership of Enterprise PI governance and strategy 2) Leadership of core HNS PI team with accountability for maintaining operations for existing programs as well as identifying, vetting and implementing new programs 3) Directing all Blue to Blue and ASO PI program invoicing processing and billing activities.

Requirements

High School Diploma/GED required.
Requires minimum of 15 years of Health Care experience focused in payment integrity; operations; compliance; vendor oversight and contract negotiations.
Requires minimum of 15 years of managerial experience with demonstrated ability to develop high performance teams.
Requires minimum of 10 years of demonstrated experience in major project implementations.
Requires minimum of 5 years experience in leading high complex and technical PI program implementations as well as experience with end to end claims processing and/or experience with managing IT code editing platforms.
Requires demonstrated experience in developing and monitoring financial controls.
Requires minimum of 10 years in negotiating complex contracts Payment Integrity vendor contracts.
Requires minimum of 3 years experience with formal PI workgroups across vendors; Sister Plans and at the Association.
Requires demonstrated experience to communicate successfully internally and externally with all levels of management, including those at the highest level of the Organization. (i.e.: C-suite and Commissioner at DOBI).
Requires minimum of 5 years demonstrated ability to manage multiple high level projects simultaneously.
Requires strong working knowledge of end to end claims processing.
Requires strong working knowledge of regulatory and mandated requirements.
Requires deep understanding of up and downstream impacts and considerations.
Requires strong knowledge of industry standard: PI capabilities; pricing and contracting methodologies.
Requires demonstrated superior analytical and problem solving abilities, includes root cause analysis and resolution.
Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
Requires an extensive working knowledge of Blue Card operation.
Deep knowledge on market intelligence.
Strong knowledge on medical cost based financials and overall claim processing.
Requires demonstrated facilitation and relationship management skills.
Demonstrated ability to make decisions with little need for direction and to function effectively as a team oriented, self-starter working across cross-functional lines.
Requires leadership style and characteristics necessary to effectively perform in this role include: strong work ethic; results-oriented; persuasive; motivational; able to make rational decisions in difficult situations; confident; high-energy; integrity; collaborator; ability to work with teams; and passionate about continuously improving and providing high quality results.
Requires ability to build strong inter- and intra- departmental.
Skilled in building partnerships with management, staff, stakeholders and vendor partners to achieve department goals and objectives.
Strong negotiation skills with the demonstrated ability to secure stakeholder agreement.
Requires strong and demonstrated knowledge linking business, technical and legal requirements to mitigate risk and managing cross functional teams.
Strong experience investigating and identifying trends and converting trend data into actionable results and reports.
Detailed knowledge of claim process system functions and capability.

Nice To Haves

Bachelor degree in Business Administration or Business Management preferred or relevant experience in lieu of degree.
Prefers Master's degree in health care administration, finance, or business administration or equivalent work history.
Decisiveness, action-orientation, results focused, capability to persevere in difficult situations, and a focus on strategic leadership issues highly desired.
Incumbent should also possess an open, collaborative leadership style that promotes teamwork and partnership while achieving desired results.

Responsibilities

Has primary accountability for the Enterprise Payment Integrity Governance Office (PIO) as co-chair and leading subject matter expert on PI driving 90% of PI savings.
Oversight of all activities, performance, and reporting associated with Payment Integrity across the enterprise.
Oversees Enterprise PI Governance within a matrixed structure to evaluate future PI business initiatives; vendor offerings and once approved maintains responsibility for tracking and reporting on the progress of these initiatives.
Ensures overall program quality and accuracy of all PI programs as well as the accompanying supporting detail and summary reporting.
Ensures initial and on-going Enterprise compliance with Association PI mandates.
Ensure parity and continued competitiveness of the Enterprise’s PI capabilities.
Partners with CBU Leadership in support of Requests for Proposal highlighting the Enterprises PI offerings and to generate revenue stream.
Serves as the corporate steward for all existing and potential PI service offerings and represents the Enterprise on multiple Vendor Client Strategy Committees; Association PI Committees and Blues PI Workgroups.
Negotiates and owns vendor contracts for multiple strategic vendor partners and their subsidiaries with an expense of over $40M annually and serves as Vendor Relationship Owner (VRO) at an Enterprise Level for at least three vendor partners.
Accountable for identifying PI contributions to enterprise cost reduction efforts by: Optimization of vendor contracts.
Accountable for identifying PI contributions to enterprise cost reduction efforts by: ensuring Horizon is appropriately reimbursed for the costs of delivering PI savings to ASO accounts.
Accountable for identifying PI contributions to enterprise cost reduction efforts by: ensuring Horizon is appropriately reimbursed for PI capabilities provided for Sister Plan members Hosted by Horizon and ensures accurate payments for services invoiced by Sister plans for reciprocal arrangement.
Identify and proactively guard against wasteful and/or abusive billing patterns and ensures timely critical regulatory reporting including but not limited to summarizing existing and planned MCO Enterprise capabilities.
Partner with senior leaders across the organization to development and maintain executive/sales Payment Integrity presentations to be used by the sales organization as part of bids for accounts as well as to sell payment integrity programs to ASO accounts to lower their medical costs.
Primarily accountable to Enterprise for prepayment and post payment activities, supporting claim payment accuracy including but not limited to: provider billing accuracy.
Primarily accountable to Enterprise for prepayment and post payment activities, supporting claim payment accuracy including but not limited to: coding accuracy.
Primarily accountable to Enterprise for prepayment and post payment activities, supporting claim payment accuracy including but not limited to: proper application of benefit; contract and utilization management determinations.
Primarily accountable to Enterprise for prepayment and post payment activities, supporting claim payment accuracy including but not limited to: ensuring system adjudication accuracy of contract, medical and reimbursement policies.
Primarily accountable to Enterprise for prepayment and post payment activities, supporting claim payment accuracy including but not limited to: member eligibility.
Oversees four strategic vendor partners who in combination with five HNS Core PI teams support multiple PI programs that deliver annual on-going PI medical cost savings over $500M across all lines of business.
Ensure annual updates of more than 2 dozen reimbursement policies.
Benchmarks against fellow Blues to identify additional PI capabilities and scans industry for new and growing PI capabilities.
Researches industry policy, pricing and contract norms to identify additional PI opportunities and leverages vendors, OIG, CMS and PI workgroups to learn of new and growing areas of wasteful spend and evaluates Enterprise impact.
Reviews and approves ROI and Business case development in support of expanding current PI Program capabilities or introduction of net new PI capabilities.
Leads and partners with key enterprise stakeholders (including the EPMO, Legal, IT, Compliance, Service Operations, Contracting, Network Relations, SIU, Government Affairs, Behavioral Health partners, FEP, Government Programs, Mandates, Actuary, Procurement and Risk Management) and vendors to evaluate benefits, costs, and implementation impacts associated with potential PI offerings or enhancements to delivery annual incremental medical cost savings of approximately $20M per year.
Presents final opportunities to Executive Leadership for endorsement/approval and ultimately accountable for program implementation and results.
Directs multiple project teams in implementing PI capabilities utilizing Enterprise standard project methodology including: Business Requirement Document development.
Directs multiple project teams in implementing PI capabilities utilizing Enterprise standard project methodology including: Technical Requirements Document development.
Directs multiple project teams in implementing PI capabilities utilizing Enterprise standard project methodology including: Budget forecasts.
Directs multiple project teams in implementing PI capabilities utilizing Enterprise standard project methodology including: Development of Test/User cases.
Directs multiple project teams in implementing PI capabilities utilizing Enterprise standard project methodology including: development of Communications Plans.
Directs multiple project teams in implementing PI capabilities utilizing Enterprise standard project methodology including: Development of required workflows and reporting.
Directs multiple project teams in implementing PI capabilities utilizing Enterprise standard project methodology including: Validation of SIT & UAT results.
Directs multiple project teams in implementing PI capabilities utilizing Enterprise standard project methodology including: development pf post production War Room for larger project implementations in support of effective project implementations.
Reviews and approves Operational Budget Transfers on an annual basis in concert with Project management Office and Finance to ensure appropriate all appropriate operational costs are captured and are aligned the business case.
Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries.
Oversee the development and maintenance of workflows and automation to enable monthly validation and payment of invoices received from in excess of 10 Sister Blues for Host Services performed for Horizon out of state members with an estimated value for 2023 of over $7M/year.
Oversee the development and maintenance of workflows and automation to enable issuing and reconciliation billing to ASO accounts for PI services performed on their accounts for both Home and Host Services in excess of $12M per year.
Oversee the development and maintenance of workflows and automation to enable creating, issuing and reconciliation of invoices to bill Sister Blues for Horizon’s PI services as Host Plan with an approximate value of $5M/year.
Partners with and provides thought leadership to senior PI leaders across Blue plans to lobby Association regarding PI parity requirements and billing; represents Enterprise at Association and Blues Plan PI Party Governance and Working Groups.
Oversee development and maintenance of purchase orders to facilitate invoice reconciliation and budgets supporting PI billing and invoicing of Sister Blues and ASOs valued in excess of $5M annually.