Pay Range:

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Why this job matters:

Conduct complex, in-depth analysis of claim payments and its methodology, identifying trends and patterns, to ascertain cost avoidance/overpayment recovery opportunities. Apply root cause analysis to design and develop solutions to payment integrity opportunities/issues, and coordinate implementation efforts with internal stakeholders as well as vendor(s) and providers as applicable. Ensure medical claims, records, and other documentation essential to claims submission and reimbursement is in compliance with state and federal guidelines, provider contracts, BCBSRI policy, national coding guidelines and industry standards. Detect areas of billing inefficiencies, internal control weaknesses, and noncompliance and provide recommendations for corrective action plans.

What you will do:

• Conduct a thorough analysis of all medical claims for adherence to state and federal guidelines, provider contracts, BCBSRI policy, national coding guidelines and industry standards. 

• Create new recurring and ad-hoc reports to identify cost avoidance/overpayment opportunities using large data sets on multiple variables. Provide data, analysis and recommendations to management on all findings affecting payments; including policy, contract issues, provider errors, pricing, systems and claim processes.

• Work with internal stakeholders to make any necessary technical updates to the system, policies and procedures when necessary as well as coordination of education to providers. Track and report progress of prospective and retrospective cost avoidance/overpayment recoveries.

• Carry out new recovery concepts within the established deadlines with a high level of accuracy. Resolve any challenges made to the proposed cost avoidance/overpayment concepts throughout the organization, including but not limited to Provider Relations, Provider Contracting, Medical/Payment Policy and Legal.

• Build strong stakeholder relationships and deliver solutions that meet stakeholders’ expectations; establish and maintain effective relationships – both internal as well as external.

• Develop written reports in accordance with reporting standards. Ensure that all audit findings, exceptions and proposed adjustments to work papers/communication documents are well defined and explained or included in reports.

• Perform other duties as assigned.

What you need to succeed:

• Bachelor’s degree in Business, Healthcare, Finance, Mathematics, Statistics or related field; or an equivalent combination of education and experience

• Seven or more years of experience in medical claims review or claims processing

• Seven or more years of experience in quantitative or statistical analysis (preferably in health care)

• Experience using PC SAS (preferably Enterprise Guide SAS), Crystal, SQL, and/or Business Objects.

• Proven analytic expertise using Microsoft Excel and Access, database query capabilities, and ability to evaluate data at all levels of detail

• Experience with manipulating large datasets

• Experience with medical terminology, claim audit procedures, provider contracts, claims processing procedures and guidelines.

• Knowledge of medical claims data

• Knowledge of Correct Coding Initiative (CCI) guidelines

• Audit skills and the ability to interpret and apply Federal and State regulations, coding and billing requirements.

• Demonstrated ability to review analytical, data and audit findings to identify coding trends and risk areas.

• Ability to interpret contract reimbursement schedules and policies

• Strong organizing skills, with the ability to prioritize and respond to shifting deadlines

• Ability to manage diverse and deadline-oriented workflow

• Strong analytical, conceptual, and problem-solving skills to evaluate complex business requirements

The extras:

• Knowledge of diagnostic related groups (DRG’s) and American Hospital Association Official Coding Guidelines

• Knowledge of Current Procedural Terminology (AAPC Certification preferred)

• Familiarity and ability to interpret hospital/provider contracts

• Familiarity with medical claims reimbursement

• Financial/Accounting methodology exposure

• Experience with lean or six sigma

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