Payment Integrity Professional Reimbursement Policy Sr. Specialist

About the Role:

Reporting to the Director of Professional Reimbursement Strategy, the Payment Policy Sr. Specialist serves as a trusted subject matter expert on professional provider payments, claims reimbursement integrity, and fee schedule administration. Operating as part of a high-impact, collaborative team, this role is critical to advancing BCBSMA’s core strategic objective of healthcare affordability and payment transparency. You will bridge clinical coding principles, payment policy formulation, claims data analytics, and vendor partnerships to ensure provider payments accurately reflect contract terms and regulatory guidelines.

This role is eligible for the following personas: Flex (2 days per week on-site in Boston or Hingham, MA, on designated collaboration days).

Your Day to Day:

1. Payment Policy Formulation & Governance: Lead the development, drafting, review, and operational implementation of new and revised professional payment policies. Evaluate clinical coding guidelines, state and federal billing regulations, and provider contract structures to align claims adjudication with intended reimbursement practices.

2. Claim Editing Logic & Reimbursement Controls: Design, evaluate, test, and maintain claim editing rule logic across enterprise claims adjudication systems. Partner closely with IT and operational systems teams to translate reimbursement strategies into automated pre-payment and post-payment billing rules that eliminate improper or duplicative claim spending.

3. Fee Schedule Oversight & Pricing Maintenance: Oversee and maintain professional fee schedules and drug reimbursement schedules. Evaluate, model, and price new and existing CPT, HCPCS, and ICD-10 codes, ensuring timely system loads, regulatory compliance, and alignment with corporate trend management objectives.

4. Claims Analytics & Financial Trend Modeling: Analyze comprehensive claims data against provider reimbursement methodologies and industry benchmarks. Assess financial, operational, and network impacts to quantify medical cost savings, uncover emerging payment integrity opportunities, and deliver data-driven recommendations to leadership.

5. Vendor Management & Strategic Inquiry Triage: Manage and expand pre-payment integrity vendor programs, including identifying prospective vendor solutions, evaluating technical capabilities, supporting contract negotiations, and monitoring service deliverables. Serve as primary SME to triage, investigate, and resolve complex inquiries submitted to the professional reimbursement inquiry mailbox.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.  

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.

We’re Looking For:

• In-depth knowledge of professional coding conventions and guidelines including CPT, HCPCS Level II, ICD-10-CM, CMS Correct Coding Initiatives (CCI), National Correct Coding edits (NCCI), and CMS-1500 billing instructions.

• Demonstrated hands-on experience evaluating, writing, or managing rule logic within commercial claims editing and payment integrity software engines (e.g., Lyric/ClaimsXten, Optum/CES, Cotiviti, or proprietary claims adjudication systems).

• Proven capability to query, manipulate, and analyze large-scale healthcare claims data sets using Excel (advanced formulas, pivot tables, modeling) and analytical database tools to measure financial variance and ROI.

• Experience managing third-party payment integrity vendors, reviewing statement-of-work deliverables, and collaborating across cross-functional teams including Actuarial, Network Management, IT, Clinical Operations, and Legal/Regulatory Compliance.

• Certified Professional Coder (CPC) and/or Certified Outpatient Coder (COC) through AAPC or AHIMA strongly preferred.

What You Bring:

• Bachelor’s degree from an accredited institution in Healthcare Administration, Business, Health Informatics, Finance, or a related field (or equivalent relevant professional experience and training). High school diploma or GED equivalent required.

• Minimum of 5+ years of relevant healthcare industry experience, with a dedicated focus on health plan reimbursement methodologies, professional payment integrity, claims operations, or medical billing and coding.

• Thorough understanding of standard commercial and government reimbursement structures (e.g., RBRVS, RVUs, fee-for-service, bundled payments, and percent-of-charge arrangements).

• Exceptional written and verbal communication skills, with the ability to distill complex coding and reimbursement logic into clear executive summaries, policy proposals, and provider-facing communications.

• Strong problem-solving aptitude with demonstrated ability to balance multiple high-priority initiatives and meet project milestones within a fast-paced health plan environment.

What You’ll Gain:

• High-Impact Strategic Visibility: You will play an active role in shaping BCBSMA’s medical affordability roadmap. Your findings and policy proposals directly influence corporate trend management, network provider interactions, and executive decision-making.

• Professional Development & Mentorship: Access to BCBSMA’s modular development programming, cross-functional mentoring circles, internal and external learning classes, and reimbursement industry credentialing support.

• Comprehensive Total Rewards: Competitive salary and incentive plan, comprehensive medical, dental, and vision coverage, 401(k) retirement match, employee pension plan contribution, and student loan repayment assistance.

• Wellness & Work-Life Balance: Generous paid time off, dedicated health and mental well-being days, a monthly commuter transit/parking subsidy (up to $275/month for Flex workers), ergonomic home office technology kits, and participation in our vibrant Employee Resource Groups (ERGs).

• Culture of Inclusion: An environment where differences are celebrated. We are committed to closing the confidence gap and empowering every associate to bring their authentic self to work as we pursue equitable, high-quality healthcare for all members.

K & Above: This position is eligible for the Flex persona.

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.