Mgr Payment Integrity (Hybrid) at Independence Blue Cross LLC in Philadelphia, Pennsylvania

Job Description:

Bring your drive for excellence, team orientation and customer commitment to Independence; help us renew and reimagine our business and shape the future of health care.  Our organization is looking to diversify, grow, innovate and serve, and we are looking for committed, empowered learning-oriented people to join our team.  If this describes you, we want to speak with you.

Job Summary

Provide team leadership in the execution of all audit and claim payment accuracy functions.  Set team strategy for comprehensive audit and claim accuracy review and evaluation.  Serve as departmental subject matter expert, liaison, and lead on corporate, association and payment integrity initiatives.  Leads and manages the most problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters. Provider education and guidance to associates on proper audit and claims accuracy methods. Uses self-directed decision making and problem solving that directly impacts financial outcomes and results.

Key Responsibilities:

• Supports Payment Integrity and Audit functions


• Serves as vendor claims processing expert, liaison or point of contact for successful achievement of vendor work


• Serves as primary contact with all operational areas to obtain and maintain policy and general information regarding provider contracting, fee schedules, EDI edits, provider bulletins, and other information relevant to audit decisions


• Serves as program or project subject matter expert or departmental lead to vendor partners 


• Develops interdepartmental procedures to ensure audit results are implemented and overpayments are retracted, and future incorrect billings are precluded.


• Interacts with provider to clarify clinical issues, documentation, and billing practices.


• Determines, develops, and approves professional and institutional audit types, reviews policies, sampling criteria and reports, audit techniques, and other tools to identify overpayments, and possible waste and abuse


• Drives new audit areas by screening and analysis or audit samples


• Evaluate complex algorithms, review data sets, independently problem solve and research data anomalies  


• Provides recommendations and guides payment integrity team on audit outcomes and improved data clarity


• Evaluates and manages claim continuum activity and financial receivables


• Serves as work, technical and project subject expert for internal IBC Audit staff


• Trains and guides other associates on data segmentation, payment integrity functional updates and audits


• Communicates autonomously with payment integrity team and management, communicates enhancements, implements system corrections and updates


• Interprets data, analyze results and opportunities

Job Requirements:

• Bachelor's degree or equivalent, Master's Preferred


• 10+ years of relevant experience, healthcare, payment integrity or health insurance a plus


• Advanced level experience with Excel and other data systems


• Good communication skills, analytical skills, Microsoft Office Suite, data visualization


• Extensive Knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record / billing documentation


• Demonstrated analytical skills and investigative skills 


• Working Knowledge of project and work management methods and practices related to provider audit


• Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes


• Ability to interact with business and data management functions


• Strong problem-solving skills


• Excellent communication skills, both written and verbal


• Hybrid of Choice - Independence has implemented a “Hybrid of Choice” model which provides our associates with the flexibility to choose whether to work remotely, work in the office every day, or work in the office on certain days at their discretion. However, management may require our associates to work from Independence’s physical office locations on certain occasions. This role is designated as a role that fits into the “Hybrid of Choice” model. While associates may work remotely, the work must be performed in the Tri-State Area of Delaware, New Jersey or Pennsylvania.


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  Independence Blue Cross is committed to the health, safety, and well-being of our associates. In support of that focus, Independence expects all new hires to be up to date with COVID-19 vaccination and booster*. Independence’s policy provides reasonable accommodations for medical or religious reasons as required by law. The process for requesting a reasonable accommodation is communicated to candidates when they are offered employment. 

  
  

  * To be considered “up to date” with COVID-19 vaccination and booster, individuals must have received an initial series of the vaccine (whether a 1-dose or 2-dose series) and timely receive a booster once eligible.  Individuals not yet eligible to receive a booster shot will be required to timely obtain a booster once eligible.