Payment Policy Sr. Specialist

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

Required Education and Skills

• Bachelor’s degree or equivalent experience or training
• 5+ years relevant healthcare industry experience
• Strong understanding of healthcare reimbursement methodologies
• Certified Professional Coder (CPC) and certified outpatient coder (COC) preferred
• 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

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting.  We may ultimately pay more or less than the posted range, and the range may be modified in the future.  An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

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.

Note:  No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can  prevent  amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay “in the know” on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.