Payment Integrity Ideation Lead - Drives the creation of new audit concepts, data models, and reimbursement policies to reduce overpayments. They leverage AI, vendor intelligence, claims data, and policy analysis to generate new savings opportunities and shift post-pay claim rework to proactive, pre-pay claim accuracy.
Provides oversight and coordination of departmental strategic planning, business and workforce plan development, business relationship management, reporting, data and/or budget analysis and special projects as assigned.
What You Will Do
Create new recurring and ad-hoc concepts to identify cost avoidance/overpayment opportunities using large data sets on multiple variables. Provide data, analysis and recommendations to management on all findings affecting payments; including policy, contract issues, provider errors, pricing, systems and claim processes.
Integrates deep data analysis and modeling analyze complex claims, medical records, and provider contracts.
Focuses on shifting efforts upstream to pre-pay to reduce provider abrasion, administrative costs, and the need for retrospective recovery.
Provides expertise in change management and portfolio management to align with organizational goals.
Work with internal stakeholders to make any necessary technical updates to the system, policies and procedures when necessary as well as coordination of education to providers. Track and report progress of prospective and retrospective cost avoidance/overpayment recoveries.
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.
Payment integrity experience in a large payer Data Mining organization
Deep knowledge of payment integrity, payment methodologies, healthcare claim lifecycle, reimbursement policies.
Proven analytic expertise using Microsoft Excel and Access, database query capabilities, and ability to evaluate data at all levels of detail.
Ability to identify patterns and anomalies in large datasets.
Experience working with cross-functional areas to implement new audit strategies.
Proven success identifying and implementing automation opportunities (audit/workflow)
Preferred:
Experience with lean or six sigma
Experience with Facets data is highly preferred
Experience with Facets is highly preferred
WhatYou’llGet
The opportunity to work at thecutting edgeof health care delivery with a teamthat’sdeeply invested in the community
Work-life balance, flexibility, and the autonomy to dogreat work
Medical, dental, and vision coverage along withnumeroushealth and wellness programs
Parental leave and support plus adoption and surrogacyassistance
Career development programs and tuition reimbursement for continued education
401k match including an annual company contribution
WhereYou’llWork
Our Hybrid Flex approach is builton presencewith a purpose – giving you flexibility to work remotely with intentional in-person connection – that supports a workplacethat’sflexible, connected, and future focused.
In a Hybrid-Flex role,you’llwork in the office at least two days a week for collaboration and connection. In a Remote Flex role,you’llwork virtually, with a few in-office visits each year formeaningfulmoments 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 anystateslistedonthis job posting. Onsite expectations will be discussed during the interview process.
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.
$118,691.00 - $189,906.00
Skills
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It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.
Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all.
Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.
Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association.
