Blue Cross Blue Shield of Massachusetts

Ready to help us transform healthcare? Bring your true colors to blue. 

What We Need

Reporting to the Associate Director of Professional Reimbursement Strategy, the Payment Policy and Network Coding Sr. Manager is responsible for leading the research development, proposal, implementation, and maintenance of BCBSMA’s Corporate Payment Reimbursement Policies, Enterprise Code Repository Database, Annual & Quarterly HCPC/ICD10 code updates, Clinical Code Edit Solutions and Medical Cost Saving Goals.

Core functions include acting as a clinician/clinical coder & subject matter expert (SME) for all reimbursement strategy initiatives and project manages all end-to-end operational & implementation activities. This role will also be responsible for the benchmark, proactively monitor and translate industry standard payment reimbursement policies from HHS Federal Register, CMS Policy, local/national plans and facilitate with internal stakeholders to assess organizational impact and develop recommendations to management for resolution.

This role is eligible for our Flex persona.

Your Day to Day

• Lead cross-functional annual/quarterly CPT, HCPC, ASA and ICD10 CM and PCS code update review. Research and monitor State/Federal regulatory policy changes and publications such as CMS, AMA, specialty societies, AAPC, Part B News for background on new code updates, impact assessments and recommend code set up parameters.
• Manage the development of new and review of existing corporate payment reimbursement policies and works collaboratively with operations and vendors to ensure systems align with policies.
• Collaborates with Government Regulatory Affairs, Network Management, Medical Economics, Benefit Administration, Provider Services, Audit, IT and Claim Operations to determine the impact of implementing policy changes.
• Develops project plans including setting timelines and deliverables, cost benefit, documents decisions, drafts communication, knowledge sharing with the appropriate staff and seek appropriate approvals and ensuring successful completion of change.
• Manage Enterprise Code Repository Database truth source for CPT, HCPC and ICD10 code set.
• Researches, identifies, and proposes opportunities for medical cost savings for Provider Payment Reimbursement (PPRC), Trend Oversight Team (TOT) and Medical Cost Council (MCC) Committee’s.
• Responsible to understand payment reimbursement policy decision impact on Member, Provider, Regulatory, Operational and Contracting.
• Represent Payment Reimbursement team at cross-functional and inter-disciplinary meetings and on organizational project teams, and frequently interact with senior leaders, and/or functional peer group managers.
• Develop business requirements and change requests to include but not limited to: Actuary/Finance cost analysis, Clinical Editing and Nasco system configuration updates and UAT/QC test cases.
• Serve as internal and external contact for inquiries related to Payment policy, including reimbursement and billing guidelines and request for proposals (RFP’s).
• Developing Policies and Procedures, maintaining truth source repository tracking, documenting or maintaining status reports, meeting minutes, issue/risk logs, and project plans related to payment policy work.
• Support with physician fee schedules
• Develop /manage audit criteria for payment policy reimbursement opportunities when hard coding is not available or practical at the time
• Presenting updates, findings, and recommendations to leadership, peers and associates at all levels as applicable for assigned projects.
• Actively contributing to team development and internal departmental improvements
• Developing PowerPoint presentations, policy cases and policy summary briefs
• This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.

We’re Looking for

• Demonstrated competence with payment reimbursement policy research and development within a health plan, government agency, regulatory or accreditation body
• Demonstrate proficiency in coding and knowledge of the requirements of industry standards such as Medicare and or managed care regulations required
• Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment
• Strong understanding of healthcare payment and reimbursement policy
• Must be proficient in the use of computers, specifically Microsoft Office products Experience with MS Access, Power Point, Cognos Power BI database program and excel 
• Strong written and verbal communication skills
• Proficiency in working with and analyzing claims data
• Proven ability to exercise sound judgment, strong critical thinking & problem-solving skills
• Ability to manage competing priorities

What You Bring

• Bachelor Degree from an accredited college or university, in nursing or a health-related field preferred
• Certified Professional Coder (CPC-P)
• 7-10+ years in a fast paced, managed healthcare environment is required
• 7-10+ years directly work in payment reimbursement policy, payment integrity and/or clinical editing
• Proficient with CPT/HCPCS & ICD10 coding, CMS Manual, Prepayment Claim Edits. Correct Coding Initiative (OCE/NCCI) and Professional and Institutional billing guidelines
• Strong understanding of healthcare reimbursement methodologies, including PFS-RVU, AP-DRG, APC
• Experience in working with claim platform & prepay claims editing systems (Nasco, ClaimXten, CES, Cotiviti PPM/CV)

It is our mission at Blue Cross Blue Shield of Massachusetts to foster a culture that enables associates to do their best work while living happy and healthy lives. That's why we offer you a variety of ways to support your best physical, emotional, financial, and social well-being. For more information on our benefit offerings, visit https://careers.bluecrossma.org/us/en/benefits

#LI-Hybrid

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Boston, Hingham

Time Type

Full time

Salary Range: $120,600.00 - $147,400.00

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay “in the know” on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.