Principal Business Application Expert - Payment Integrity

Job Description

Develop reimbursement policies utilizing strong coding knowledge and clinical expertise. Coordinate with multiple business areas to ensure reimbursement policies and coding edits are compliant with other business requirements, such as contracting and pricing processes. Collaborate with other business areas to ensure reimbursement concepts are implemented correctly. Respond to internal and external inquiries regarding policies, benefit application and reimbursement strategies. Represent the Healthcare Division as clinical or coding advisors.

What You'll Do

Policy Development

• Provide clinical knowledge to support other business area decision making

• Use judgment and initiative to review, analyze and develop reimbursement policy solutions

• Provide coding analysis expertise and regularly considers the business implications of the policy change to the current business environment

• Create or update reimbursement policy documents to reflect coding guidance

• Assist less senior Business Systems Analysts to enhance overall team performance

Issue Resolution

• Facilitate the resolution of large, complex production system problems by

performing initial triage for severity and business impact of claim inquiries.

• Troubleshooting and analyzing to determine root cause of issues

Project/Program Support

• Work collaboratively on projects and initiatives with the business and IT by eliciting and documenting business requirements and preparing appropriate functional specifications while considering coding and clinical appropriateness and ensuring an integrated approach is used

• Act as Business Lead/Coordinator on large, complex departmental and/or some corporate projects/initiatives

• Facilitates project intake, including scheduling of projects

• Coordinates with other business areas on policy implementation and post implementation support

System Configuration

• Configure and maintain critical system tables and data elements across multiple system environments

• Analyze, develop and implement configuration changes to ensure appropriate system reimbursement

• Monitor configuration for accuracy and compliance to change control processes

What You'll Bring (Hiring Requirements)

• Registered Nurse or related undergraduate degree with 5 years of clinical/coding experience (i.e. revenue management / payment integrity)

• Bachelor's degree or advanced degree (where required)

• 8+ years of experience in related field

Nice to Have

• AAPC Certified Professional Coder (or be willing to obtain within one year of employment)

• Direct experience with automated tools to perform analysis and reporting (i.e. Business Objects, query writing)

• Project coordination experience

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets,  licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. 

*Based on annual corporate goal achievement and individual performance.
 

$91,100.00 - $164,000.00 Apply