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Blue Cross Blue Shield of Massachusetts Provider Appeals & Data Mining Manager l Health Care in Hingham, Massachusetts

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The Data-mining and Provider Appeals Manager, oversees the activities associated with the review of paid claims for coding accuracy, benefit, payment, and contract interpretation in accordance with established claims processing guidelines, medical and payment policies, established audit protocols, as well as manages activities associated provider appeals. The individual manages a team charged with understanding complex issues, requiring extensive knowledge of claim systems, standard diagnostic and procedure coding conventions, policies, quality assurance and appeals review process to accurately assess current and historical performance and identify opportunities for process and policy improvements.The Manager is responsible for the compilation and analysis of information to identify inaccurate payments and trends for root cause analysis. The Manager is also responsible for developing policies, procedures, protocols, and ongoing oversight of the identification of inaccurate payments for recovery including, analysis, drafting of recommendations, coordination of adjustments with claims and tracking of outstanding recoveries. The individual will be accountable for developing and monitoring provider appeals for all payment integrity activities and assisting with transitioning identified opportunities from post to pre-pay datamining including implementation of applicable Blue Cross Blue Shield Association mandates. The Manager develops and engages seasoned audit associates, ensuring that consistent audit protocols and appeal timelines are maintained and followed. Candidate will analyze data to improve the quality and productivity of Enterprise Payment Integrity Office (“EPIO”) appeals operation and identify trends, suggesting opportunities to improve the appeals process.

Duties and Responsibilities:

  • Responsible for the management support and guidance to Claims Data-mining program.

  • Responsible for the operational oversight and performance of payment integrity provider appeals to ensure compliance with regulatory and contractual requirements.

  • Responsible for monitoring operational queues and managing to quality and turn-around-time of EPIO appeals targets.

  • Accountable for the overall program quality and accuracy of an all data-mining audit projects as well as the accompanying supporting detail and summary reporting.

  • Accountable as the primary point of contact and responsible individual in internal and external data-mining audits and payment integrity provider appeals.

  • Responsible for ensuring that audit associates work to determine root cause of claim processing problems/errors and provides recommendations for improvement in claims process for continuous quality improvement.

  • Responsible for overall program findings and recoveries working with leadership of multiple departments across the organization including but not limited to: Network Management, Provider Contracting, Claims Operations, Benefit and Payment Policy Operations, Fraud Investigation & Prevention (FIP) Departments and Finance/Actuarial.

  • Responsible for managing all aspects of project analyses from: ideation and conceptualization, development of queries, programming, execution, and recovery/claim adjustment or claim settlement, when appropriate.

  • Responsible for leading the audit associates in the development and management of acceptable data-mining audit work plans.

  • Manages audits and produces reports of research findings for management reviews including recommendations for improvement

  • Acts as a liaison on behalf of the Provider Audit Data-mining area with other teams/departments throughout the organization.

  • Other duties and projects as assigned.

Qualification & Education Requirements:

  • BA/BS or equivalent related professional experience

  • 5-7 years of related professional experience

  • 2-4 years of experience managing teams of experienced professionals

  • 2-4 years of clinical coding experience, clinical coding certification required

  • Strong knowledge of healthcare delivery system

  • Skilled at manipulating and analyzing large data sets; knowledge of SAS or other programming language (SQL) and advanced use of MS Access and Excel

  • Excellent analytic, critical thinking and organizational skills

  • Experience with managed care contracting, medical and payment policy, reimbursement methodology

  • Broad and in-depth knowledge of financial/data analysis and the ability to function independently and creativity

LocationHinghamTime TypeFull time

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power , Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.