Director, Payment Integrity Strategy and Operations

Provides leadership and oversight for development, implementation, and execution for Payment Integrity (PI) programs focused on payment accuracy and improving member affordability. Acts a liaison for all reimbursement policies and payment integrity initiatives to communicate cost of care targets, drive ideation, prioritization, Reimbursement Policy governance, and business case development within the department and coordinate performance management and tracking at the program level. Partners with the broader Health Care and Finance divisions to stay connected on enterprise-wide efforts related to Cost of Care. Provides expertise and insights for operational improvements, savings opportunities, and partnerships to drive innovative, effective PI opportunities and collaborations.

Leadership Responsibilities

• People leadership

• Resource management

• Project planning and management

• Financial and data analysis

What You'll Do

Leadership & Direction:

Develops the strategy for Payment Integrity (PI), with a focus on cost of care efforts. Oversees initiatives and defines KPIs that are pertinent to PI to ensure align with the overall enterprise strategy.

Sets SMART goals for departmental strategies that can be measured over time to determine successes and opportunities for improvements.

Excellence in project management skills, such as project management plans with goal setting, milestone development and task management. Able to apply RACI models to effectively work with teams in developing project management plans.

Develops specification data documents for dashboard/score card development that can be shared with leaders for awareness on successes and areas for improvement.

Partners closely with the actuarial team on developing business cases for staffing and resource needs, as well as tracking cost of care and gross revenue.

Represents PI at internal enterprise ideation meetings and drives PI cost of care efforts, ideation and vetting processes, communication of project status and overall program evaluation.

Represents PI externally and collaborates with leaders at other Blues Plans, the Blue Cross Association and other payer organizations for cost of care/innovation efforts, and sharing of best practices and lessons learned.

Create and maintain a Reimbursement Policy governance committee for Commercial and Medicare lines of business to meet monthly and communicate the new or updated policies, their value, and document concerns, comments, and approvals or dissents.

Management and Operations:

Coordinates and identifies opportunities on process improvement, PI program re-design and analytics that support our programs.

Oversees internal teams to support the development of new PI models and how we engage with providers from a reimbursement perspective.

Drives internal evaluation of programs for cost of care efforts, including developing proposals with external evaluation teams and managing presentations to our internal teams.

Develops the roadmap and alignment of departmental efforts and presentations to key executive stakeholders.

Manages PI team performance and serves as an expert for our Reimbursement Policies.

Liaise with CuraCor and Health Plan teams on market intelligence needs and review market intelligence and research to remain current on industry trends

Evaluate and manage new and/or existing vendors and solution partners to align to BCNC’s strategic direction

What You'll Bring:

Bachelor’s degree and 10 years of experience in reimbursement policy, provider reimbursement, and/or strategic or product development

Must have direct health plan experience

Previous experience directly with business case development, financial and market analysis and/or process redesign

7 years leadership experience, leading people and/or complex cross-divisional projects or programs

Preferred:

Experience with Payment Integrity products and solutions

Experience with strategy frameworks/roadmaps and change management

History of high performance and leadership in a matrixed organization

What You’ll Get

The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community

Work-life balance, flexibility, and the autonomy to do great work

Medical, dental, and vision coverage along with numerous health and wellness programs

Parental leave and support plus adoption and surrogacy assistance

Career development programs and tuition reimbursement for continued education

401k match including an annual company contribution

Learn more

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

$131,900.00 - $250,600.00

SkillsAccount Management, Budgeting, Business Analysis, Cost Controls, Finance Strategy, Financial Analysis, Financial Modeling, Financial Performance Improvement, Financial Reporting and Analysis, Operational Process Improvements, Operations Management, Payment Integrity, Process Improvements, Process Optimization, Regulatory Compliance, Risk Management, Strategic Planning

RQ0017503

Remote/Remotely/Tele/Telecommute/From home