Resp & Qualifications
PURPOSE: This position directs and oversees the activities of the Payment Integrity unit for the Maryland and DC Plans. Maximum effectiveness, efficiency, and contribution to corporate profit are achieved by planning, organizing, coordinating, monitoring, and directing a variety of internal and external audits. With emphasis on payment integrity strategies, proactive review of source system analysis and other provider and member monitoring to ensure maximum overpayment recoveries are achieved. Works extensively with CareFirst VP and Director on overpayment strategies to include but not limited to recovery vendor relationships and implementation of internal recovery programs. Assists the Director with administration of the unit to ensure budgetary compliance, effective communication with management, and overall administrative efficiency and effectiveness of the unit.
RESPONSIBILITIES: Under the direction of the Director, Payment Integrity, duties include but are not limited to:
Direct and oversee all recovery activity, audits and projects that are assigned. Assist the staff in the utilization of Pareo for tracking and monitoring all overpayment adjustments for identification of provider outlier behavior, assessment and prioritization of specific cases and pursuit of recovery. Directs the successful delivery model of payment integrity services to all customers by managing the team while providing leadership and direction and ensuring that all stakeholders’ needs and expectations are met and exceeded. Develops and implements key metrics to drive performance in quality and productivity.
Direct and oversee all activity and projects within Payment Integrity. Ensuring staff are fully aware of financial recovery objectives including cost avoidance savings. Maintain accurate reporting for recoveries for all audits performed adhering to departmental policies and procedures. Consistently review recovery audits, Payment Integrity concepts and projects that are in progress to inform Director, Payment Integrity through status reports and meetings to ensure progress of overall program.
Manage the day to day activity with each external recovery vendor by providing oversight of performance. Identify and implement quality control and appropriate service level agreements in order to maintain customer satisfaction.
Lead the business requirements development for the department’s claims recovery process. Works with Director, Payment Integrity on strategic vision of operational processes. Will be responsible for executing new technologies, including reporting of all Payment Integrity work efforts including all investigative recoveries.
Assist the Director, Payment Integrity in developing a departmental strategic and operating plan, complete with goals, objectives and quality measures which outline the departmental activities and staff goals for the year. Establishing financial, quality and time measures to ensure departmental resources are effectively utilized and defined scopes are consistent with the strategic and operating plans. Utilizes information, works with staff to ensure investigations/audits are conducted timely, effectively and result in an overall achievement of targeted financial recoveries of the unit.
Hire, train, educate, supervise and evaluate staff personnel, counsel and. Ensure a competent and effective staff is fully aware of departmental guidelines, policies and procedures, and that their skills are developed and maintained through a studied selection of training opportunities. Responsible for ensuring the audit staff is properly trained and kept up-to-date with changes in medical policy, contractual issues, local, state and federal legislation and any other information which affects their work, ensuring their performance meets the needs of the program.
Acts as liaison with Medical Directors and Legal Department as necessary. Be a catalyst for change, leading staff to welcome/accept change with minimum anxiety.
Required: BS/BA degree in Accounting, Finance, Business Administration, Nursing, Criminal Justice or a related job experience. 5 years of progressive management experience within Recovery efforts, Operational experience or Payment Integrity experience and at least 5 years Vendor Management experience including implementation and oversight.
Abilities/Skills: Microsoft package, computer/systems literate, excellent verbal and written skills with demonstrable experience.
• Excellent PC skills
• Excellent oral/written communications and interpersonal skills
• 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 customer demands
• Ability to work effectively both independently and as a team member
• Proven judgement, analytical, decision making and problem-solving ability
• Ability to effectively build relationships within the provider/institutional community, with local, state and federal agencies and internal divisional and cross functional and stakeholders at all levels
• Dependable, with the highest level of integrity
• Ability to work well under pressure while assuming a leadership role
• Demonstrate a high level of sensitivity to Federal/State law
Preferred: A MS, MBA, MA, MSN degree, Insurance Background is a plus.CPC (certified professional coder) preferred.
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
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