Job Information
Blue Cross Blue Shield of Wyoming Manager of Payment Integrity in Cheyenne, Wyoming
JOB SUMMARY
The Manager of Payment Integrity is responsible for ensuring healthcare payments are processed in accordance with Blue Cross Blue Shield of Wyoming (BCBSWY) policies and procedures, applicable contractual terms, not in error or in duplicate, and free from wasteful or abusive practices. The position incumbent is accountable for building positive competent reputation, creating trusting relationships with providers, and ensuring established processes are followed through the day-to-day management of team members.
ESSENTIAL DUTIES and RESPONSIBILITIES
Responsible for ensuring the integrity of healthcare payments via the development and management of policies/procedures on fraud, waste, and abuse, guiding the tactical work of individual team members in support of payment integrity processes, and collaboratively partnering with all areas of the company that are involved in payment integrity including utilization management, subrogation, provider relations, actuary, claims, and legal, among others, including intentional collaborative activities such as facilitating payment integrity oversight committee meetings, etc.
Establishes and reinforces the BCBSWY reputation with members, providers, and other external parties, of knowledgeable, competent, trustworthy payment integrity processing via established protocols and consistent practices that ensure claims are paid correctly for eligible members, according to contractual terms, not in error or duplicate, and free of wasteful or abusive practices. Ensures FEP fraud, waste, and abuse compliance.
Responsible for the selection, ongoing training, development, and overall performance management of area staff including exempt and non-exempt individual contributors; accountabilities include day-to-day supervision, development and maintenance of staff work schedules, review and approval of time records and related payroll documents, assessment of training needs and the provision of appropriate training, as well as performance coaching and counseling.
Accountable for departmental operational and tactical goal attainment through individual work as well as by planning and managing team/individual production, developing and regularly assessing quality and quantity standard(s) achievement, tracking and updating correspondence control information as required, as well as actively troubleshooting and supporting problem-solving with team members when needed. Responsible for resolving concerns/issues that may be escalated by team members.
Ensures excellent customer service to the provider network; service goals include professional response to provider inquiries, clear oral and written communications, knowledgeable payment integrity team members, and delivering provider education, workshops, learning opportunities. Provider education is developed that fulfills objectives of increasing awareness and knowledge of BCBSWY program policies and procedures, clean claims, appeals, and other payment related items, basic processing steps, as well as reinforces BCBSWY trustworthy and competent reputation.
To enable payment process improvement and ensure strong policy, procedure and overall processing, regularly monitors errors and partners with data analysts and engages in data mining activities; monitoring activities may include electronic claims processing (ECP) errors, provider audits and investigations, and reviewing the integrity of provider billing and EFT data.
This essential duties listing is not all inclusive, but representative. Other duties may be assigned.
NON-ESSENTIAL DUTIES and RESPONSIBILITIES
May be assigned special projects that are proactive in nature resulting from industry identified occurrences/incidents and/or special projects that may be reactive to identified incidents emerging from the monitoring of fraud, waste, and abuse incidents.
Serve as BCBSWY Brand ambassador as requested; may include public-speaking, providing presentatio s, serving as facilitator for various in-house and/or external events, meetings, gatherings, etc.
May stand-in for leadership when requested/as may be needed.
APPLICABLE KNOWLEDGE, SKILLS, and ABILITIES (KSA)
Strong working knowledge of CPT and ICD-10 procedure and diagnosis coding; understanding of physician and non-physician reimbursement.
Skilled with data analysis, interpretation, and application enabling data-informed process development and process improvement.
Capable of ensuring ongoing contemporary competency and knowledge, individually as well as on a team basis, regarding coding, reimbursement, provider networks, etc.
Ability in interpersonal relations in internal and external settings; excellent listening skills, problem-solving/problem-resolution abilities, and capable of consistently exhibiting value-aligned leadership and people management.
Able to effectively communicate with a wide range of individuals at multiple levels internal, and external, to the organization; capable of establishing appropriate professional reputation for competency and trustworthiness.
Proven skills in with verbal and written communication, as well as project management enabling effective administration of complex programs throughout the development, implementation, management, and assessment stages.
QUALIFICATIONS
Earned Bachelors degree in Business, Accounting, Healthcare, or related field required. CPB, CPC, CIC, COC, or CPMA credential preferred. Commensurate experience may be considered in lieu of earned degree.
5 years experience working in a professional role requiring adherence to established protocols and compliance with ethical standards required.
1 year of experience leading and managing employees; experience with the supervision of both exempt and non-exempt team members preferred.
Active Drivers license required.
PHYSICAL/MENTAL DEMANDS and WORK ENVIRONMENT
While performing the essential duties of this position, an employee will typically experience:
- Standing, walking, and sitting.
- Lifting and/or moving up to 10 pounds; occasionally lifting and/or move up to 25 pounds short distances.
- Usage of close vision, distance vision, and ability to adjust focus.
- Manipulation of keyboards, keypads, and calculators.
- Placing and answering telephone calls.
- Focused task tracking and follow-through.
- Some interpersonal tension in problem-solving/resolution interactions.
- Speaking/presenting to internal and external audiences of diverse sizes.
- Work environment noise level that is usually moderate.
- Open office environment with few, if any, loud sounds, or ongoing auditory distractions.
- Some deadline related stress.
- As needed evening and weekend hours on a periodic basis.
- Minimal travel, typically in-state.