Payment Policy Sr. Specialist

Ready to help us transform healthcare? Bring your true colors to blue. 

Reporting to the Payment Integrity Program Manager, the Payment Integrity Consultant uses industry knowledge, research skills, payment policy and business operations knowledge to become a trusted subject matter expert on facility payments. Excelling at this work as part of a small but mighty team, is critical to BCBSMA’s goal of affordability.

Key Functions:

• Support implementation of identified opportunities to improve the effectiveness of the facility reimbursement strategy,
• Assist managing provider reimbursement strategic planning process
• Support the facility reimbursement strategic planning process and strategy execution, including gathering, analyzing, and prioritizing development needs and requirements
• Participate in facility reimbursement payment integrity activities that include developing new payment policies, revising existing payment policies to align with intended payment practice, draft proposals, assessing operational impacts, inquiries and implementation efforts.
• Assist in developing new facility claim editing logic and maintenance of existing facility rule logic to support payment integrity efforts and existing reimbursement guidelines.
• Support the development and implementation of reimbursement strategies for the successful modification and implementation of institutional provider reimbursement methodologies, to support organizational efforts around improved quality, trend management, and payment reform activities.
• Manage and expand pre-payment integrity programs
• Identify new Payment Integrity vendors as needed, negotiate contractual terms and manage the relationships
• Manage and respond to inquiries within the facility reimbursement mailbox
• Maintain and update the hospital outpatient and drug fee schedules, including assessing and pricing new codes
• Analyze claims data in conjunction with provider reimbursement methodologies and external benchmarks to assess financial impacts that will help inform payment integrity improvement opportunities and decisions
• Evaluate opportunities and translate those needs into project requirements and activities for business and/or IT to address. Deliver business requirements to address payment policy updates and/or reimbursement updates
• Other duties as assigned

Required Education and Skills

• Bachelor’s degree or equivalent experience or training
• 5+ years relevant healthcare industry experience
• Strong understanding of healthcare reimbursement methodologies
• Certified Professional Coder (CPC) and certified outpatient coder (COC) preferred
• Proficiency in working with and analyzing claims data
• Strong written and verbal communication skills
• Knowledge of CPT/HCPCS & ICD10 coding, Correct Coding Initiatives and UB04 billing
• Strong critical thinking & problem-solving skills
• Ability to manage competing priorities
• Experience in working with claims editing software

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Hingham

Time Type

Full time

Salary Range: $87,930.00 - $107,470.00

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.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and