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Blue Cross NC · 1 day ago

Director, Payment Integrity - Coordination of Benefits and Data Mining

United States

Full-time

Remote

Senior Level, Lead/Staff

$158K/yr - $253K/yr

10+ years exp

Blue Cross NC is seeking a Director of Payment Integrity to lead strategic and operational priorities within the Payment Integrity domain. The role involves managing teams to optimize systems and processes, implement initiatives for efficiency, and ensure compliance with regulations while driving growth and savings in the coordination of benefits and data mining verticals.

Financial ServicesHealth InsuranceInsurance

Comp. & Benefits

Responsibilities

Direct, manage and lead highly complex functional and/or broad foundational business areas within Payment Integrity to define and enable strategic and operational priorities

Lead and set goals for teams 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

Provide leadership, vision, and direction for assigned teams

Direct staff of subject matter experts and analysts to identify & execute growth business initiatives, while managing existing programs: production problem resolution, system enhancements, and configurations

Accountable to define and execute strategy to deliver year-over-year growth and achieve savings target(s) within the COB and Data Mining vertical

Ensure business plans and industry analysis, consider future needs and drive “best in-class" thinking. Builds understanding of market trends and customer needs

Identifies new operational initiatives and modifications to current programs and processes to improve the company’s competitive position/increase medical expense savings

Demonstrates understanding of the financial levers that impact business performance and deploys them to improve short- and long-term results

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

Ensure programs and operations are performing successfully and are compliant in accordance with regulations of State, Federal, and other governing bodies; ensures corrective action plans are implemented when applicable

Develop internal PI Provider Education program to enhance provider experience and focus on change in behavior

Qualification

Payment Integrity managementHealth plan experienceFinancial analysisVendor managementClaims adjudication systemsProject managementData mining conceptsCodingBillingLeadership