Offer summary

Qualifications:

Bachelor’s degree in a relevant field., At least 10 years of experience in reimbursement policy or provider reimbursement., Previous health plan experience is required., 7 years of leadership experience managing teams or complex projects..

Key responsibilities:

Develop and oversee Payment Integrity strategies and initiatives.

Manage internal teams and coordinate process improvements.

Represent Payment Integrity at internal and external meetings.

Evaluate and manage vendors and external partners.

Job description

Job Description

Provides leadership and oversight for development, implementation, and execution for Payment Integrity (PI) programs focused on payment accuracy and improving member affordability. Acts a liaison for all reimbursement policies and payment integrity initiatives to communicate cost of care targets, drive ideation, prioritization, Reimbursement Policy governance, and business case development within the department and coordinate performance management and tracking at the program level. Partners with the broader Health Care and Finance divisions to stay connected on enterprisewide efforts related to Cost of Care. Provides expertise and insights for operational improvements, savings opportunities, and partnerships to drive innovative, effective PI opportunities and collaborations.

Leadership Responsibilities
• People leadership
• Resource management
• Project planning and management
• Financial and data analysis

What Youll Do

Leadership & Direction:

Develops the strategy for Payment Integrity (PI), with a focus on cost of care efforts. Oversees initiatives and defines KPIs that are pertinent to PI to ensure align with the overall enterprise strategy.
Sets SMART goals for departmental strategies that can be measured over time to determine successes and opportunities for improvements.
Excellence in project management skills, such as project management plans with goal setting, milestone development and task management. Able to apply RACI models to effectively work with teams in developing project management plans.
Develops specification data documents for dashboardscore card development that can be shared with leaders for awareness on successes and areas for improvement.
Partners closely with the actuarial team on developing business cases for staffing and resource needs, as well as tracking cost of care and gross revenue.
Represents PI at internal enterprise ideation meetings and drives PI cost of care efforts, ideation and vetting processes, communication of project status and overall program evaluation.
Represents PI externally and collaborates with leaders at other Blues Plans, the Blue Cross Association and other payer organizations for cost of careinnovation efforts, and sharing of best practices and lessons learned.
Create and maintain a Reimbursement Policy governance committee for Commercial and Medicare lines of business to meet monthly and communicate the new or updated policies, their value, and document concerns, comments, and approvals or dissents.