Pay Range:

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Why this job matters:

Oversee and direct programs that create a strong Payment Integrity program by developing/enhancing exiting vendor relationships and seeking new vendor relationships in alignment with the corporate strategy. Manage daily operations of the payment integrity department; lead the strategic program expansion of claims audit and recovery, including all claims editing programs. Foster and maintain collaborative relationships with providers, serving as the organization’s liaison when conducting paid claim audits.  Oversee the development of work plans to schedule and manage team resources to meet audit timelines.  Ensure the integrity of the financial reporting of the department.  Direct and assist team in the interpretation of health care and claims payment information.   Provide subject matter expertise for corporate initiatives as it relates to audit and claims editing software areas including claims processing, contractual language, and industry standard coding conventions. Collaborate with Executive Leadership and internal business areas to ensure effective health care delivery; develop and disseminate initiatives that improve performance as related to member and provider satisfaction, financial stability, and technology enhancements.  Ensure programs, plans, and policies align with the company’s philosophy and objectives. 

What you will do:

• Lead work teams and provide direction and technical guidance to audit and recovery staff.  Provide strategic leadership and direction to management including performance management oversight and implementation of best-in-class techniques and tools.
• Provide direction to department staff regarding prioritization of areas to focus audit efforts.  Develop work plans in conjunction with Division leadership to schedule and manage team resources to achieve intended audit results. Facilitate processes to continually identify new areas of opportunity including potential new and innovative vended service offerings.  Responsible for meeting/exceeding budget, resource, and other commitments of the department.
• Oversee the financial integrity of the department’s recoveries. Ensure that the tracking of the recovery unit financial activities includes timely follow-up with Claims, Finance, and/or providers. This includes compliance with all BCBSA rules related to payment integrity and the inclusion of self-funded groups in conjunction with the BCBSRI Sales/Marketing team. Ensure monthly recovery statistics are reported to Senior Management.
• Determine strategic direction of department’s internal training and education approach.  Maintain professional awareness of tools and techniques available to improve the quality of analysis and enhances their technology literacy.
• Manage the oversight, direction and integration of numerous multi-disciplinary programs and initiatives spanning across the enterprise in support of the long-term Medical Expense Trend team savings goals.
• Assist initiative leadership and MET subgroup leads in the development of timelines, milestones, and success metrics for distinct projects and develops ongoing assessments.
• Develop accurate and timely summaries for executive management that provide consolidated, clear, and concise assessments of strategic initiatives implementation status.
• Facilitate opportunities for shared knowledge, resources, and better integration between distinct projects and initiatives via thorough understanding of individual project critical paths. Work with the Director of Provider Relations on opportunities for provider education as identified in the Payment Integrity programs.
• Lead or participate in work teams and committees comprised of senior management to assess and evaluate overall strategic implementation roadmap.
• Perform other duties as assigned.

What you need to succeed:

• A combination of education and related work experience
• Five to seven years of management experience or experience leading a team.
• Five to seven years of experience in payment integrity, Correct Coding Initiative (CCI) or medical billing operations experience.

• Strong working knowledge of Microsoft Office products (including advanced level in Excel and Access)  
• Knowledge of health care financing, delivery models and associated information support strategies to facilitate improved health plan and provider decision-making.
• Ability to coach and motivate to maximize performance.
• Ability to effectively communicate goals and business objectives to employees.
• Strong and effective decision-making skills
• Strong organization and time management skills
• Ability to think creatively and drive innovation.
• Ability to collaborate and while dealing with complex situations.
• Ability to influence up and across the organization.
• Ability to effectively delegate work and manage project tasks
• Strong negotiating, influencing, and consensus-building skills
• Excellent verbal and written communication skills, with ability to convey complex or technical information in an effective manner

The extras:

• Bachelor’s degree in business, Nursing, Health Information Administration, or related field; or an equivalent combination of education and experience
• Strong working knowledge of Microsoft Office products to include advanced level ability in Excel and Access  
• Knowledge of healthcare billing and coding convention, reimbursement methodology, and provider contracting strategies
• Experience in hospital or professional billing practices and maximization of coding rules.

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia