Job DescriptionThe Provider Education Program Manager is responsible for designing, implementing, and managing a health plan provider education program focused on identifying and addressing billing patterns indicative of potential upcoding, documentation variance, and other provider billing outliers. This role uses claims, coding, and reimbursement data to identify providers with aberrant billing patterns; develops and distributes provider education letters; conducts outreach and follow-up calls; performs quarterly and semiannual monitoring to assess behavior change; and partners with Payment Integrity, Provider Relations, Compliance, and Special Investigations Unit (SIU) teams to escalate cases when educational intervention does not result in sustained improvement.
What You'll Do Program Development & Oversight- Develop and maintain the health plan's provider education program for coding, documentation, and billing integrity issues, with a focus on potential upcoding and other aberrant provider billing patterns.
- Establish program workflows, referral criteria, outreach templates, monitoring schedules, escalation pathways, and reporting standards to support compliant and consistent operations.
- Create standardized processes for provider identification, educational intervention, follow-up review, and referral to SIU when concerning behavior persists.
Data Analysis & Outlier Identification- Analyze claims, coding, utilization, reimbursement, and provider billing data to identify outlier patterns, unusual coding distributions, trending variances, and potential upcoding concerns.
- Conduct targeted reviews using CPT, HCPCS, ICD-10, modifier usage, and documentation-related indicators to determine whether provider billing patterns warrant education or further escalation.
- Partner with payment integrity, analytics, and coding subject matter experts to validate findings, quantify impact, and prioritize outreach opportunities.
Provider Education & Outreach- Draft and issue provider education letters that clearly describe identified billing concerns, applicable coding/documentation expectations, and recommended corrective actions. Comparable education-focused coding roles emphasize post-audit reports, findings summaries, and provider-facing education communications.
- Conduct provider outreach calls and meetings to review findings, explain coding or documentation expectations, answer questions, and reinforce compliant billing practices.
- Develop educational materials, job aids, presentations, and provider-specific feedback to support improved coding accuracy and billing compliance.
Monitoring & Behavior Change Assessment- Perform quarterly and semiannual post-education monitoring to assess whether provider billing behavior changes after outreach and whether additional intervention is needed. While the exact monitoring cadence is program-specific, comparable audit/education roles include baseline, routine periodic, and focused follow-up reviews to track improvement.
- Document measurable outcomes such as coding trend shifts, reduction in outlier behavior, education completion, and cases escalated for further review.
Escalation & SIU Referral Management- Develop and administer a formal referral process to SIU for providers whose billing patterns do not improve following education or whose behavior suggests potential fraud, waste, or abuse. SIU-related coding roles commonly support referrals by reviewing claims, records, and concerning billing patterns and preparing case summaries for investigative action.
- Prepare referral summaries, supporting documentation, trend analyses, and case narratives for submission to SIU, Compliance, or legal/regulatory partners as appropriate.
What You Bring - Bachelor's degree or advanced degree (where required)
- 8+ years of experience in related field.
- In lieu of degree, 10+ years of experience in related field.
Bonus Points- CPC, CCS (Required), CEMA, CPMA (Strongly Preferred), CPIP (Nice to have) or similar coding/compliance certification.
- Experience in managed care, Medicare, Medicaid, Marketplace, or commercial health plan operations.
- Experience with provider education, payment integrity vendor outputs, post-pay review, overpayment recovery, or FWA/SIU workflows.
- Advanced Excel, dashboarding, and data visualization skills. Comparable payment integrity analyst roles emphasize Excel and data analysis capability.
- Strong knowledge of CPT, HCPCS, ICD-10, modifiers, documentation standards, reimbursement methodology, CMS guidance, and payer billing requirements.
What You'll Get - The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community
- Work-life balance, flexibility, and the autonomy to do great work
- Medical, dental, and vision coverage along with numerous health and wellness programs
- Parental leave and support plus adoption and surrogacy assistance
- Career development programs and tuition reimbursement for continued education
- 401k match including an annual company contribution
- Learn more
Where You'll WorkOur Hybrid Flex approach is built on presence with a purpose - giving you flexibility to work remotely with intentional in-person connection - that supports a workplace that's flexible, connected, and future focused.
In a Hybrid-Flex role, you'll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you'll work virtually, with a few in-office visits each year for meaningful moments that matter.
Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.
#LI-Hybrid
Salary RangeAt Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.
*Based on annual corporate goal achievement and individual performance.
$107,901.00 - $172,642.00
SkillsBudget Management, New Program Development, People Management, Program Coordination, Program Evaluations, Program Implementation, Program Management, Program Strategy, Project Management, Strategy Development
