Resp & Qualifications
PURPOSE: To prevent loss to CareFirst BlueCross BlueShield through the supervision, management and direction of individuals performing the review of claims and medical records in a Prepay environment on claims identified as at risk of fraud, waste, and/or abuse resulting in the savings of claims expense. Responsible for providing leadership and guidance to Special Investigations staff performing reviews, assisting management in the direction and day-to-day running of the Department, maintain and improving department policies and procedures, providing on-going training, coaching less experienced staff in making claims decisions, reporting, and collaborating with internal and external partners.
PRINCIPAL ACCOUNTABILITIES: Under the direction of the Manager, functions include but are not limited to:
1. Day-to-day supervision and performance management of the Prepay Team. This includes supporting management, providing input into the coordination, planning, organizing and direction of the prepay claims process and workload. Supervising, training, developing, and conducting regular performance reviews of staff. Assisting manager with the development and revision of departmental goals, policies, procedures, and objectives to prevent increased claims expense as the result of fraud, waste, and abuse. Providing insight and judgement on claims payment decisions regarding coding and documentation on both foreign and domestic claims. Apply knowledge of provider policy and contractual requirements to claims payment decisions. Conduct quality reviews on departmental work and make recommendations for improvement both to individual team members and department process.
2. Ensures timely department process completion, including claims turnaround times, and completion of monthly reports. Utilizes approved case tracking system and the FEP SIU Tracking System (FSTS).
3. In conjunction with team perform root cause analysis on issues and cases worked by the department to identify problems and provide recommendations to management and the payment integrity workgroup, as they relate to risk mitigation and effective external/internal controls for CareFirst Business Operations.
4. Manage providers on prepay review including additions, changes, and removal. Perform coding accuracy and billing pattern analysis of providers on prepay review to determine behavior change and remove from prepay review or help create additional education and communications tor the provider to influence behavior change.
5. Perform special projects to meet the needs of the Special Investigations Unit.
Required: A 4-year college degree and 7 or more years of work experience in insurance, claims processing, management, investigations, health care, nursing or law enforcement, at least 3 of which must be health care or insurance specific, and includes experience independently leading fraud, waste and abuse investigations or serving in a lead or higher position in a claims processing environment.
A coding certification such as Certified Professional Coder (CPC) equivalent or higher is required.
• Excellent PC skills, including demonstrated use of Microsoft Office Suite
• Excellent oral/written communication and interpersonal skills
• Leadership skills
• Ability to identify and improve business processes
• Ability to communicate technical and non-technical language to technical and non-technical persons
• Highly motivated, with strong drive, team spirit and organizational skills
• Ability to prioritize multiple tasks to meet established deadlines and satisfy internal and external customers’ demands
• Ability to work effectively both independently and as a team-member
• Proven judgment, analytical, decision making and problem-solving ability
• Effectively interact with internal and external associates at all levels
• Dependable, with the highest level of integrity
• Demonstrate a high level of sensitivity to Federal/State law
Preferred: In depth knowledge of corporate and divisional policies and procedures, process improvement (Lean or Six Sigma certifications), claims processing, medical policies, healthcare billing and/or other related systems and procedures to determine the integrity of claims’ payments and business operations within CareFirst or other health care organization.
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: 4/16/2020
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 on Federal health care programs.
The associate 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 associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship