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Resp & Qualifications
PRINCIPAL ACCOUNTABILITIES: Under the direction of Manager, SI Payment Integrity, the principle duties and responsibilities include, but are not limited to, the following:
Identifies, develops, and implements new concepts that will target claim overpayment scenarios for each of CareFirst SBU’s. Performs analysis on claims, provider data, enrollment data, medical policies, claim payment policies for payment integrity concepts for recovery opportunities. Performs analysis of business unit data and policies, applying thorough understanding of each line of business’s specific procedures, to make recommendations to SI Management and SBU Management to reduce and/or eliminate erroneous payment exposure with minimal direction. Identifies and reports back to SI and SBU Management root cause analysis when overpayment and cost avoidance concepts are identified. Responsible for not only the recovery of the concept but working with each SBU to make any necessary technical update to avoid the overpayments moving forward.
Tracks and reports progress of current prospective and retrospective cost avoidance/ overpayment recovery concepts. Responsible for carrying out new concepts within the established deadlines with a high level of accuracy. Responsible for resolving any challenges made to the proposed cost avoidance/overpayment concepts throughout the organization working with Provider Network, Provider Contracting, Medical management and policy and Legal. Stakeholder in a cross functional working team to develop and implement new overpayment/cost avoidance concepts.
Reviews claims edit concept results for quality assurance and proof of concept validation.
Reviews all available sources including federal and state statutes, regulations, provider manuals, Provider contracts, and bulletins for changes to and/or new payment rules.
Identifies and documents changes to and/or new payment rules or language in the source document which may be utilized to update existing system edits or new system edits.
Department: Post Payment Unit
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 4/29/2018
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly to Federal health care programs.
The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The employee is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship