Director Claims Payment Integrity Post Payment

Provider Audit and Reimbursement
16767 Requisition #
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The Director, Claims Payment Integrity – Post-Payment is responsible for providing program direction and oversight of the Claims Payment Integrity Post-Payment Team. This department provides post-payment review, processing and receivables management capabilities to ensure over/underpaid claims are identified and remediated to meet regulatory, fiduciary and customer requirements and expectations through consistent statewide provider audit programs. This position serves as a significant conduit between Florida Blue and its provider community, post pay audit Vendors, Plan partners within the Association and functional areas across the Enterprise.

Job duties include but are not limited to:

• Actively participate in the strategy design and subsequently direct the functions of the Claims Payment Integrity Post-Payment teams responsible for the identification of claims payment errors (both over and under payments) and subsequent overpayment recovery and reconciliation processes. Claim payment error findings typically result from aberrant provider billing practices, coding errors and internal payment errors. Audits are completed in compliance with legal and statutory requirements, including OIR, Blue Cross Blue Shield Association (BCBSA), Federal Employee Program (FEP), Medicare and provider and group contractual agreements
• Lead strategic efforts to identify, implement and manage partnerships with post pay audit vendors to maximize audit coverage and results.
• Develop and maintain superior professional relationships with key stakeholders and internal functional areas designed to ensure program consistency across lines of responsibility throughout the Enterprise
• Design and direct continuous improvement program to document the root causes of claims payment errors, report causes to appropriate functional areas within the Payment Integrity Office and the enterprise at large for corrective action and monitor on-going progress to address root causes
• Design and implement audit programs that support alternative reimbursement, integrated care and risk sharing models
• Directly participate in provider contracting improvement opportunities, including audit contract language with providers. Meets regularly with key internal stakeholders and senior-level hospital stakeholders relative to audit issues to support improved provider relations
• Report on a monthly basis audit overpayment identifications, audit underpayment identifications, audit recoveries, accounts receivable collection activities and medical cost savings to applicable Company staff and senior executives. Provide formal presentations of audit program information both internally and externally as requested
• Identify and provide resources to support professional development of staff to increase competencies meet continuing education requirements and provide opportunities for personal growth
• Administer Corporate policy as communicated from internal functional areas as they relate to Claims Payment Integrity post-payment audit activities. Communicate policy to audit staff for implementation in daily activities
• Monitor provider feedback related to audit activities, implement correction action where required to address provider issues and meet business needs. Support positive provider relations by providing on-site provider education related to billing and coding issues and reacting to provider information requests
• Direct focused provider audits to support the BlueCard Program and audits of NASCO accounts which meet or exceed BCA requirements or Control Plan expectations in cooperation with BCBSA

Job Requirements:
• Bachelor’s degree or equivalent work experience
• 6+ years related work experience or equivalent combination of transferable experience and education. Experience Details: Provider audit, internal audit or financial audit
• 3+ years direct supervisory/management experience
• Knowledge of Federal and State regulations related to provider audit activities
• General knowledge of provider billing and coding practices
• Experience implementing and managing vendor partnerships
• Demonstrated ability to assemble teams and develop talent
• Experience utilizing data analytics and familiarity with IT capability development
• Demonstrated ability to develop and maintain relationships (both internal and external)
• Demonstrated ability to champion change and develop an environment that is open and willing to actively seek and respond to change
• Strong communication skills

• Master’s degree
• Formal Audit or Coding Certification Credentials
• Knowledge of the Blue Cross and Blue Shield business practices, rules and the BlueCard system
• Knowledge of Federal and State regulations governing provider and claims post-payment auditing
• Experience managing relationships with providers, including large hospital systems

We are an Equal Opportunity Employer/Protected Veteran/Disabled.

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