Job Description

Your Role

The Payment Integrity team is responsible for ensuring healthcare claims are paid accurately, both in a pre-pay and post-pay context. Some examples of payment integrity include validating coding rules, determining the correct party, membership eligibility, contractual adherence, and conducting root cause analysis to prevent errors. This team is responsible for over $400M+ of cost of healthcare savings and avoidance annually and is also responsible for developing new capabilities to improve cost of healthcare exposure and performance, managing multiple third-party partners in pursuit and prevention of over-payments. The Business Analyst Consultant of Payment Integrity will report to the Director of Payment Integrity. In this role you will collaborate with various internal teams and vendors to improve cost of healthcare and premium cost outcomes.

Your Work

In this role, you will:

• Provide highly complex analytical support through the analysis and interpretation of data in support of cross-functional business operations
• Lead the development of annual operating plans, capital budgets and forecasts, and build business cases for new business initiatives (cost/benefit analysis)
• Develop, prepare, and analyze reports with highly complex analysis and data for management review, and presents to various levels of management
• Define business requirements and provide analysis to increase operational efficiency
• Provide analytical support for multiple, highly complex cross-functional projects simultaneously, establish work plans and timelines, coordinates with internal and external resources
• Lead the evaluation, design, development, and implementation of new products that will improve Blue Shield’s payment integrity performance
• Identify novel avenues of pursuit for the improvement of payment accuracy
• Work with internal teams and external vendors on complex initiatives aimed at achieving cost savings and increased effectiveness
• Validate payment integrity concepts through interpretation of provider contracts, review of regulatory guidelines, and system configuration
• Identify root cause of issues through data analysis and collaborate with other teams to reduce payment errors
• Participate in issue resolution by providing analytic support and collaborating with various internal stakeholders

Your Knowledge and Experience

• Requires a bachelor’s degree or equivalent experience
• Requires at least 7 years of prior relevant experience
• In depth experience with payment integrity practices and related operations preferred
• Possess strong data/analytic, financial, and process experience
• Familiarity with medical claim coding standards and concepts
• SQL expertise desired
• FACETS claim processing system experience desired

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