Independence Blue Cross · 17 hours ago
Provider Reimbursement Spec
Philadelphia, PA
Contract
Onsite
Mid Level
3+ years expIndependence Blue Cross is seeking a Provider Reimbursement Specialist to manage and implement systems that administer managed care contract provisions. The role involves coordinating fee schedules, ensuring accurate provider data, and developing relationships with internal clients to resolve payment-related issues.
Health CareHealth InsuranceInsuranceMedical
Responsibilities
Selects, implements, and loads the system applications that administer managed care contract provisions
Assigns the rate coding to ensure the system takes the appropriate discounts, per diems, case costs, and fee schedule
Coordinates implementation and verification of the loading of the fee schedule
Examines fee schedules for proper coding
Prepares the system entry to adjudicate contract provisions
Creates and maintains networks and delivery systems in provider file system
Assists in training and development of procedures for provider loading processes
Administer set-up for all fee for service payment systems for both IBC and AmeriHealth
Develop and facilitate working relationships with departments that interact with Physician Reimbursement
Employ those relationships with internal clients to resolve issues related to provider payment, pricing, and Medical Policy as it pertains to provider payment
Maintain and track special pricing requests via a database and reports statistics from that database as necessary
Review and recommend pricing for claim suspends that falls under the responsibility of Physician Reimbursement
Audit claims history as needed to ensure accurate pricing set up and Medical Policy changes related to pricing
Researches, analyzes and assesses business requirements for the development of system initiatives relating to the corporate provider file and other systems which access the corporate provider file data either electronically or through data extracts
Devise new fee codes and recommend pricing methods to support contracting, claim payment policy and medical policy
Interfaces with business area to define requirements and coordinates with IS and other designated areas to achieve desired results
Compiles project specifications
Monitors projects to ensure deadlines are met
Maintain detailed and accurate records of meetings, tasks, and timelines
Ensures that management and other designated individuals are apprised of project status through written communications and by preparing and conducting project related presentations
Creates and administers testing scenarios
Monitors testing and implementation of systems
Communicates findings to other business areas
Makes recommendations for project enhancements or modifications to meet requirements
Identifies modifications required for the corporate provider file to meet the business requirements for all of the IBC FOC provider needs
Performs regular audits of provider data to ensure the accuracy of data loaded to the corporate provider file and identifies areas for improvement
Qualification
Required
Bachelor's degree in business, Health Care, or a related field/commensurate work experience
In lieu of a BS/BA degree, extensive experience and knowledge of (3-5 years) IBC's various operating systems is acceptable
In-depth knowledge of managed care and professional payment systems is required
A demonstrated knowledge of various operational departments including Claims, Medical Policy, Contracting, Specialty Programs, Benefits, and Network Services is preferred
The ideal candidate will be self-motivated, highly organized, detail-oriented, able to handle multiple high priorities, as well as possess above average problem solving, analytical and communication skills (both written and verbal)
An established ability to interact with all levels of management is required
Proficiency with Excel and Access are required
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app
Preferred
The ideal candidate will be self-motivated, highly organized, detail-oriented, able to handle multiple high priorities, as well as possess above average problem solving, analytical and communication skills (both written and verbal)
A demonstrated knowledge of various operational departments including Claims, Medical Policy, Contracting, Specialty Programs, Benefits, and Network Services is preferred
Proficiency with Project is preferred
Knowledge of computer assisted audit techniques is desirable
Company
Independence Blue Cross
The leading health insurer in southeastern Pennsylvania. It is a sub-organization of Independence Blue Cross.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Alexandra Jorgensen
Senior Vice President Human Resources
Joe Geist
SVP & Market President, National
Recent News
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2026-01-14
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