Director, Payment Integrity Clinical Coding Review

Job Description

Direct, manage and lead highly complex functional business area within Clinical Coding Review (CCR) to define and enable strategic and operational priorities. Lead and set goals for the CCR team responsible for identifying, coordinating, and implementing initiatives/projects and activities that create efficiencies, optimize systems & processes, promote quality, and maximize medical and administrative expense savings. Teams may include CCR operations, clinical, coding and specialty programs, multiple CCR services either performed by vendors or internally, opportunity analysis, vendor evaluation, solution design, and vendor service delivery management. Provides expertise and insights for new services, operational improvements, and partnerships to drive medical expense and administrative cost savings. Champion innovation while identifying opportunities and collaborations that drive value for Blue Cross NC members and savings for Blue Cross NC.

What You'll Do

• Provide leadership, vision, and direction for assigned teams
  • Accountable for all decisions within the group
  • Determine team priorities to reflect the organization’s core values and deliverables
  • Develop, coach and motivate others to take actions that support and reflect the core values and desired future state

• Direct staff of subject matter experts and analysts on supporting business initiatives, production problem resolution, system enhancements, and configurations
• Lead and oversee management and delivery of enterprise and departmental projects including business case development, ROI analysis, planning, business analysis, and project management
• Lead and oversee optimization of existing systems, processes, and workflows
• Direct the overall integrity and functionality of departmental business applications and processes
  • System administration to include oversight of system configuration for owned applications. Configuration could be done by internal staff and/or external vendors. 
  • Product implementation and enhancement support
  • Research, analysis, and user assessment of technology and systems to ensure adequate application support

• Serve as business owner for key corporate, divisional, and departmental initiatives
• Oversee the development and ongoing evaluation of performance and production metrics and goals, including process measures, outcomes measures and financial measures
• Responsible for accurate reporting and forecasting of medical expense savings and administrative costs as well as budget oversight 
• Leverages significant Payment Integrity and CCR expertise to support key stakeholders and partners. Responsible for supporting key stakeholders where Payment Integrity and CCR expertise is required (examples include ASO and IPP Host billing, provider inquiries into payment integrity interventions applied to their claims, and Legal inquiries)
• Oversee or participate in internal committees relevant to work responsibilities; may represent the department through presentations and/or active participation in cross functional organizational committees
• Represent the organization at external meetings with vendors, providers and customers as the clinical coding review expert and decision maker when needed
• Create new clinical coding teams internally to enhance internal capabilities

What You'll Bring

• Bachelor’s degree and 10 years of experience managing multifunctional clinical coding, payment integrity or related teams 
• In lieu of bachelor’s degree, 12 years of experience as stated above
• 7 years leadership experience 
• RN, LPN, or another relevant clinical licensure required
• Certified Professional Coder required

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   

Salary Range

At 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.
 

$131,900.00 - $250,600.00

Skills

Account Management, Budgeting, Business Analysis, Cost Controls, Finance Strategy, Financial Analysis, Financial Modeling, Financial Performance Improvement, Financial Reporting and Analysis, Operational Process Improvements, Operations Management, Payment Integrity, Process Improvements, Process Optimization, Regulatory Compliance, Risk Management, Strategic Planning