Blue Cross & Blue Shield of Rhode Island · 3 weeks ago
Lead Prov Payment Integ Analyst
Providence, RI
Full-time
Hybrid
Mid, Senior Level
$93K/yr - $139K/yr
7+ years expBlue Cross & Blue Shield of Rhode Island is dedicated to serving the healthcare needs of Rhode Islanders. The Lead Prov Payment Integ Analyst will conduct complex analyses of claim payments, identify trends, and develop solutions for payment integrity issues while ensuring compliance with guidelines and policies.
Insurance
Responsibilities
Conduct a thorough analysis of all medical claims for adherence to state and federal guidelines, provider contracts, BCBSRI policy, national coding guidelines and industry standards
Review, research, and interpret medical record documentation, claims data, contractual guidelines, payment methodologies and system adjudication to identify trends and patterns in complex claims payment data that result in recovery opportunities
Create new recurring and ad-hoc reports 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
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
Carry out new recovery concepts within the established deadlines with a high level of accuracy. Resolve any challenges made to the proposed cost avoidance/overpayment concepts throughout the organization, including but not limited to Provider Relations, Provider Contracting, Medical/Payment Policy and Legal
Build strong stakeholder relationships and deliver solutions that meet stakeholders’ expectations; establish and maintain effective relationships – both internal as well as external
Introduce best practices around post-payment recoveries
Provide ongoing feedback to key internal stakeholders with the goal of improving internal payment control and reducing payment inconsistencies/overpayments
Perform audit peer review analysis periodically to assure quality of results and consistency in content, analytics and adherence to department policies and procedures
Develop written reports in accordance with reporting standards. Ensure that all audit findings, exceptions and proposed adjustments to work papers/communication documents are well defined and explained or included in reports
Manage appeals process with providers and third-party arbitrators when necessary
Mentor less experienced staff
Lead department projects and initiatives
Perform other duties as assigned
Qualification
Required
Bachelor's degree in Business, Healthcare, Finance, Mathematics, Statistics or related field; or an equivalent combination of education and experience
Coding Certification (CPC, CCS, CPMA or equivalent)
Seven or more years of experience in medical claims review or claims processing
Seven or more years of experience in quantitative or statistical analysis (preferably in health care)
Experience using PC SAS (preferably Enterprise Guide SAS), Crystal, SQL, and/or Business Objects
Revenue cycle/revenue integrity experience
Proven analytic expertise using Microsoft Excel and Access, database query capabilities, and ability to evaluate data at all levels of detail
Experience with manipulating large datasets
Experience concisely communicating complex analyses to gain consensus across departments on overpayment items
Experience turning internal recommendations and industry concepts into potential cost saving
Experience with medical terminology, claim audit procedures, provider contracts, claims processing procedures and guidelines
Knowledge of medical claims data
Knowledge of managed care practices
Knowledge of Correct Coding Initiative (CCI) guidelines
Knowledge of all claim forms and coding types, including UB-04, CMS 1500, ICD-9 and ICD-10, HCPC, revenue codes, NDC coding, HIPPA, HEIDIS, and NCQA
Demonstrated ability to constructively and sensitively provide feedback to providers regarding federal and state coding, medical documentation and compliance guidelines, audit results and risk areas
Audit skills and the ability to interpret and apply Federal and State regulations, coding and billing requirements
Demonstrated ability to review analytical, data and audit findings to identify coding trends and risk areas
Ability to interpret contract reimbursement schedules and policies
Strategic and critical thinking skills
Strong analytical skills
Strong business acumen and political savvy
Strong negotiation skills
Strong written and verbal communication skills
Strong problem-solving skills
Ability to work effectively with a wide variety of people in individual and group settings
Strong organizing skills, with the ability to prioritize and respond to shifting deadlines
Strong time management skills
Ability to manage diverse and deadline-oriented workflow
Strong analytical, conceptual, and problem-solving skills to evaluate complex business requirements
Preferred
Knowledge of diagnostic related groups (DRG's) and American Hospital Association Official Coding Guidelines
Knowledge of Current Procedural Terminology (AAPC Certification preferred)
Familiarity and ability to interpret hospital/provider contracts
Familiarity with medical claims reimbursement
Financial/Accounting methodology exposure
Experience with lean or six sigma
Benefits
Flexible work arrangements that include remote and hybrid opportunities
Paid time off
Tuition reimbursement
Assist with student-loan repayment
Health, dental, and vision insurance
Programs that support your mental health and well-being
Competitive pay
Bonuses and investment plans
Additional paid time to volunteer
Company
Blue Cross & Blue Shield of Rhode Island
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), we know that health is more than what happens at the doctor’s office.
501-1000 employees
H1B Sponsorship
Blue Cross & Blue Shield of Rhode Island has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (4)
2024 (4)
2023 (2)
2022 (4)
2021 (3)
Funding
Current Stage
Late StageLeadership Team
Martha Wofford
President and CEO
James Joy
Chief Financial Officer - Retired
Company data provided by crunchbase