Director Claims Payment Integrity

Our Claims Payment Integrity team is seeking a Director to lead critical work that strengthens payment accuracy and drives meaningful affordability results for our members. In this role, you will have the opportunity to work with high-performing internal teams and vendor partners to enhance the accuracy of claims payments, ensure alignment with nationally recognized coding and billing standards, and play a key role in the company’s Fraud, Waste, and Abuse (FWA) program.

This position offers the opportunity to directly influence medical cost savings and support the organization’s mission of improving affordability for our customers. Expertise in using AI-enabled automation to improve operational outcomes is strongly preferred.

Although this is a remote position, quarterly  travel to our Chattanooga, TN headquarters will be required. Additionally, travel to our Chattanooga headquarters will be required for final interviews.

Note: Sponsorship is not available for this role.

Job Responsibilities

• Overseeing payment integrity programs (claims audits, pre-pay edits, vendor products, etc.) and implementing best practices, procedures and policies for the claim payment integrity functions. 
• Directing and leading payment integrity teams analyzing all evidence that provider payments are appropriate and accurately reflect billing / coding standards, company policies, provider contracts, and member benefits.; and identifying opportunities for fraud, waste or abuse control and prevention.
• Researching healthcare related questions as necessary to support business areas and investigations and staying abreast of current medical coding and billing issues, trends, and changes in laws/regulations.
• Maintaining and building relationships with external payment integrity vendors, various business units, Special Investigations Unit and senior management to ensure communication of critical issues in a timely manner.
   

Job Qualifications

Education

• Bachelors degree in business, healthcare or relevant field or equivalent work experience required

Experience

• 10 years - Experience in the health care industry required
• 5 years - Experience in a leadership/management role required
• 1 year - Experience with data analytics required
• 1 year - Auditing or other relevant experience required
• 1 year - Claims or operations experience preferred

Skills\Certifications

• Excellent oral and written communication skills
• Excellent interpersonal and team building skills
• Effective and concise presentation skills

Number of Openings Available

1

Worker Type:

Employee

Company:

BCBST BlueCross BlueShield of Tennessee, Inc.

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.