Dir Payment Integrity

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, thereâ??s no greater time for forward-thinking professionals like you to join us in delivering on it!

As a member of Team Blue, youâ??ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

The Director of Payment Integrity will own the end-to-end Enterprise-level Payment Integrity (PI) program and performance management functions. As part of this role, this person is expected to lead cross-functional teams in the planning, design, implementation, and ongoing maintenance of the framework to ensure the success of this critical program. The incumbent will develop the strategic roadmap to recover, eliminate, prevent unnecessary medical-expense spending, and lead the execution for a comprehensive claim accuracy program. The incumbent will optimize pre/post claim editing, audit, coordination of benefits, subrogation/work comp, fraud, waste and abuse, and claim recovery programs that will drive incremental value year over year. This incumbent will employ use of analytics, trends, competitor benchmarking, and outcomes to continually identify savings opportunities, develop mitigation strategies to avoid future overpayments/underpayments, and implement plans to achieve business goals.

What you'll do:

• Establish a highly accountable payment integrity unit capable of proactively identifying and investigating payment issues and working with stakeholders to develop mitigation strategies to prevent future occurrences, with ability to review impacts holistically.
• Develop a comprehensive, strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending by reviewing upstream and downstream processes (i.e., benefit and/or provider configuration, rate loads, rate assignments, COB, claims payment logic, etc.)
• Provide vendor management oversight and partnership with internal and external entities to ensure that the appropriate operational processes are in place and proper follow up/communications are occurring
• Lead the execution and maintenance of a corporate claim accuracy program by optimizing pre/post payment integrity function programs.
• Develop and deploy mitigation strategies to avoid future overpayments and drive incremental value year over year in both medical and administrative cost savings.
• Direct and oversee financial recovery vendors, ensuring overpayments identified are valid and recouped.
• Develop and monitor a strong high dollar claim review program.
• Direct financial adjustment unit to ensure overpayments identified are properly recouped and financial recoveries reconciled to ensure expected outcome is fully recovered.
• Lead and manage the most problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters.
• Direct the evaluation of performance edits and potential issues, perform/support root cause analysis, and successfully mitigate operational risk in advance, to the extent possible, to minimize or eliminate impact.
• Serve on workgroups to develop new initiatives that have impact on reimbursement to ensure that any new procedures or policies are consistent with overall corporate business objectives and can be implemented cost-effectively ensuring payment accuracy.
• Leverage broader business relationships, systems, and knowledge to enable team to achieve goals.
• Ensure adherence to all legislative, regulatory, and contractual requirements.
• Establish strong partnership with Provider relations and the Provider Network Operations Department and provide support for provider communications related to claim payment integrity disputes and financial determination of under or overpayments.
• Develop, implement, and maintain payment integrity policies and procedures.
• Lead, manage, and optimize the Inter-plan invoicing process.
• Act as a consultant for senior management from other departments for, but not limited to, reimbursement methodologies, processing protocols, and provider negotiations.
• Develop PI performance management program, including goals and Key Performance Indicators based on performance trends, opportunity analyses, and market-based benchmarks. Submit monthly updates to key stakeholders.
• Foster a culture of accountability that emphasizes people and performance management, coaching and development, and employee engagement.

To be considered for this position, you must have:

• Bachelorâ??s degree required
• A minimum of 8 yearsâ?? senior leadership experience, with at least 5 years of experience in claims management in the healthcare or insurance industry
• Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation
• Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes.
• Advance level experience with Excel and other data systems
• Proven track record in building and fostering relationships at all levels of the organization
   

An equivalent combination of education and experience may be substituted for this requirement.

The ability to meet or exceed the attendance and timeliness requirements of their departments.

The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned.
 

The strongest candidates for this position will also possess:

• Strong problem-solving skills
• Excellent communication skills, written and verbal
• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Demonstrated ability to lead and develop others

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.

Blue Cross and Blue Shield of Nebraska is an Equal Opportunity /Affirmative Action Employer - Minorities/Females/Disabled/Veterans