Principal Business Operations Advisor

Job Description

Payment Integrity Ideation Lead - Drives the creation of new audit concepts, data models, and reimbursement policies to reduce overpayments. They leverage AI, vendor intelligence, claims data, and policy analysis to generate new savings opportunities and shift post-pay claim rework to proactive, pre-pay claim accuracy.

Provides oversight and coordination of departmental strategic planning, business and workforce plan development, business relationship management, reporting, data and/or budget analysis and special projects as assigned.

What You Will Do

• Create new recurring and ad-hoc concepts to identify cost avoidance/overpayment opportunities using large data sets on multiple variables. Provide data, analysis and recommendations to management on all findings affecting payments; including policy, contract issues, provider errors, pricing, systems and claim processes.

• Integrates deep data analysis and modeling analyze complex claims, medical records, and provider contracts.

• Focuses on shifting efforts upstream to pre-pay to reduce provider abrasion, administrative costs, and the need for retrospective recovery.

• Provides expertise in change management and portfolio management to align with organizational goals.

• Work with internal stakeholders to make any necessary technical updates to the system, policies and procedures when necessary as well as coordination of education to providers. Track and report progress of prospective and retrospective cost avoidance/overpayment recoveries.

What You Bring

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

• 8+ years of experience in related field.

• In lieu of degree, 10+ years of experience in related field.

• Payment integrity experience in a large payer Data Mining organization

• Deep knowledge of payment integrity, payment methodologies, healthcare claim lifecycle, reimbursement policies.

• Proven analytic expertise using Microsoft Excel and Access, database query capabilities, and ability to evaluate data at all levels of detail.

• Ability to identify patterns and anomalies in large datasets.

• Experience working with cross-functional areas to implement new audit strategies.

• Proven success identifying and implementing automation opportunities (audit/workflow)

Preferred:

• Experience with lean or six sigma

• Experience with Facets data is highly preferred

• Experience with Facets is highly preferred

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.
 

$118,691.00 - $189,906.00

Skills

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