Blue Cross Blue Shield of Nebraska
Dir Payment Integrity
Blue Cross Blue Shield of Nebraska, Fort Wayne, Indiana, United States, 46804
At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.
Our team is the power behind that promise. As the industry rapidly evolves, we seek ways to optimize business processes and customer experiences.
As a member of Team Blue, you'll find purpose, opportunities, and the support you need to build a meaningful career and make a powerful impact in our community.
Director of Payment Integrity
The Director of Payment Integrity will own the end-to-end Enterprise-level Payment Integrity (PI) program and performance management functions. This person is expected to lead cross-functional teams in the planning, design, implementation, and ongoing maintenance of the framework to ensure the success of this critical program. The incumbent will develop the strategic roadmap to recover, eliminate, prevent unnecessary medical-expense spending, and lead the execution for a comprehensive claim accuracy program. What you'll do: Establish a highly accountable payment integrity unit capable of proactively identifying and investigating payment issues and working with stakeholders to develop mitigation strategies. Develop a comprehensive, strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending. Provide vendor management oversight and partnership with internal and external entities. Lead the execution and maintenance of a corporate claim accuracy program. Develop and deploy mitigation strategies to avoid future overpayments. Direct and oversee financial recovery vendors. Develop and monitor a strong high dollar claim review program. Direct financial adjustment unit to ensure overpayments identified are properly recouped. Lead and manage complex audit assignments. Direct the evaluation of performance edits and potential issues. Serve on workgroups to develop new initiatives impacting reimbursement. Leverage broader business relationships to achieve goals. Ensure adherence to all legislative, regulatory, and contractual requirements. Establish strong partnership with Provider relations. Develop, implement, and maintain payment integrity policies and procedures. Lead, manage, and optimize the Inter-plan invoicing process. Act as a consultant for senior management. Develop PI performance management program. Foster a culture of accountability emphasizing people and performance management. To be considered for this position, you must have: Bachelor's degree required. A minimum of 8 years' senior leadership experience, with at least 5 years of experience in claims management in the healthcare or insurance industry. Extensive knowledge of health care provider audit methods and provider payment methods. Proven ability to apply quantitative and/or qualitative research and data analysis techniques. Advanced level experience with Excel and other data systems. Proven track record in building and fostering relationships at all levels of the organization. An equivalent combination of education and experience may be substituted for this requirement. The ability to meet or exceed the attendance and timeliness requirements of their departments. The ability to work well in a team environment and build positive relationships. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned. The strongest candidates for this position will also possess: Strong problem-solving skills. Excellent communication skills, written and verbal. Integrity and Trust. Customer Focus. Functional/Technical skills. Demonstrated ability to lead and develop others. Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers. We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members. Blue Cross and Blue Shield of Nebraska is an Equal Opportunity /Affirmative Action Employer - Minorities/Females/Disabled/Veterans.
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The Director of Payment Integrity will own the end-to-end Enterprise-level Payment Integrity (PI) program and performance management functions. This person is expected to lead cross-functional teams in the planning, design, implementation, and ongoing maintenance of the framework to ensure the success of this critical program. The incumbent will develop the strategic roadmap to recover, eliminate, prevent unnecessary medical-expense spending, and lead the execution for a comprehensive claim accuracy program. What you'll do: Establish a highly accountable payment integrity unit capable of proactively identifying and investigating payment issues and working with stakeholders to develop mitigation strategies. Develop a comprehensive, strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending. Provide vendor management oversight and partnership with internal and external entities. Lead the execution and maintenance of a corporate claim accuracy program. Develop and deploy mitigation strategies to avoid future overpayments. Direct and oversee financial recovery vendors. Develop and monitor a strong high dollar claim review program. Direct financial adjustment unit to ensure overpayments identified are properly recouped. Lead and manage complex audit assignments. Direct the evaluation of performance edits and potential issues. Serve on workgroups to develop new initiatives impacting reimbursement. Leverage broader business relationships to achieve goals. Ensure adherence to all legislative, regulatory, and contractual requirements. Establish strong partnership with Provider relations. Develop, implement, and maintain payment integrity policies and procedures. Lead, manage, and optimize the Inter-plan invoicing process. Act as a consultant for senior management. Develop PI performance management program. Foster a culture of accountability emphasizing people and performance management. To be considered for this position, you must have: Bachelor's degree required. A minimum of 8 years' senior leadership experience, with at least 5 years of experience in claims management in the healthcare or insurance industry. Extensive knowledge of health care provider audit methods and provider payment methods. Proven ability to apply quantitative and/or qualitative research and data analysis techniques. Advanced level experience with Excel and other data systems. Proven track record in building and fostering relationships at all levels of the organization. An equivalent combination of education and experience may be substituted for this requirement. The ability to meet or exceed the attendance and timeliness requirements of their departments. The ability to work well in a team environment and build positive relationships. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned. The strongest candidates for this position will also possess: Strong problem-solving skills. Excellent communication skills, written and verbal. Integrity and Trust. Customer Focus. Functional/Technical skills. Demonstrated ability to lead and develop others. Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers. We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members. Blue Cross and Blue Shield of Nebraska is an Equal Opportunity /Affirmative Action Employer - Minorities/Females/Disabled/Veterans.
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