Resp & Qualifications PURPOSE: The Payment Policy Manager will ensure that CareFirst maintains accurate, compliant, and financially sound payment policies to support consistent claims adjudication and a value-based health care system. This role is responsible for the research, development, maintenance, and implementation of corporate payment and reimbursement policies aligned with regulatory requirements, provider contracts, and corporate payment strategy. We are looking for an experienced people leader in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.
ESSENTIAL FUNCTIONS: - Manages the research, development, maintenance, and implementation of corporate payment and claims adjudication policies. Collaborates with internal and external partners, including provider contracting, claims operations, and regulatory entities, to interpret and apply payment policies to new or revised benefit and reimbursement structures.
- Accountable for corporate systems, processes, and strategies that translate payment policy into claims adjudication rules and configuration. Partners with claims technology teams to assess, customize, and deploy payment logic across appropriate platforms.
- Supports network management and contributes to the research and development of corporate reimbursement policies that drive consistent claims payment, improved provider satisfaction, reduced administrative appeals, reduced interest payments, and reduced regulatory complaints.
- Represents the division on matters of payment and reimbursement policy to influence provider, subscriber, and community relationships. Evaluates opportunities and recommends future initiatives or partnerships to improve internal and external customer outcomes.
- Manages day-to-day activities of the Payment Policy function, including managing, coaching, and guiding associates. Develops annual goals and manages departmental budget planning and variance analysis to ensure appropriate allocation of resources.
SUPERVISORY RESPONSIBILITY: This position manages people.
QUALIFICATIONS: Education Level: Bachelor's Degree in Health Administration, Business, Finance, Nursing or related discipline OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Licenses/Certifications Upon Hire Preferred: - Certified Coder (CCS or CPC)-AHIMA or AAPC AAPC Certified Professional Coder (CPC) or AHIMA Certified Coding Specialist (CCS).
Experience: 5 years experience in a health insurance environment with focus on payment policy, reimbursement policy, claims operations, or policy implementation and 1 year supervisory experience or demonstrated progressive leadership.
Preferred Qualifications: - MBA, Healthcare Administration, or related discipline.
- Experience with Medicare Advantage or Medicaid.
Knowledge, Skills and Abilities (KSAs) - Knowledge of payment policy, reimbursement structures, and claims adjudication.
- Knowledge of healthcare operational, legal, ethical, and compliance requirements.
- Proven ability to mentor, coach, and develop associates to meet performance goals.
- Use of Microsoft Office applications (Excel, PowerPoint, Word).
- Understanding of coding standards and payment logic.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $114,080 - $211,761
Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
PHYSICAL DEMANDS:The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US Must be eligible to work in the U.S. without Sponsorship
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