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Blue Cross Blue Shield of Massachusetts Director l CPC, CCS, CIC, COC, CRC l Enterprise Payment Integrity Office in Boston, Massachusetts

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At BCBSMA, we consider Payment Integrity - the activities conducted to ensure accurate and timely claim payment on behalf of our customers – to be at the core of our business success. The role of the Director, Enterprise Payment Integrity, is a highly visible leader that will drive measurable incremental value to the organization and our customers in the form of medical trend mitigation and administrative cost savings. This includes leadership oversight of internal teams of audit professionals and management of a complimentary suite of claims audit vendor relationships. This position will be the play a critical, lead role externally with software and solution vendors, consulting firms on the evaluation and implementation of new capabilities and programs. The Associate Director will also play a key role nationally, representing BCBMA interests on the BCBS Association Payment Integrity Task Force. The expectation of this function is to lead a team charged with ensuring appropriate claim payments across the local provider system, ensuring accurate service coding, efficient first pass claim processing, recovery of inappropriately paid claims and resolving the systematic root cause. The Director will lead the development of a leading-edge enterprise payment integrity program strategy, as well as drive the approved implementation of the developed strategy for BCBSMA’s payment accuracy solutions and roadmap. This individual will have responsibility for understanding and prioritizing market needs, performing competitive analysis, performing discovery for new products and market needs, and leading delivery and program launches for new Payment Integrity capabilities.

Key Responsibilities:

Reporting to the VP of Payment Strategy and Integrity, this individual will be accountable for developing program vision, features, functions, and delivering customer and market impact for enhancements to payment integrity programs. The successful candidate will demonstrate a unique blend of leadership, domain expertise, business acumen, creativity, business judgment, industry knowledge, and analytical knowledge. They will have spent time in recent years working to understand the changing healthcare payer and/or provider landscape and have a strong understanding of payment integrity programs.

  • Vision: Leverages his/her subject matter expertise to provide input into BCBSMA’s Payment Integrity strategic plan; collaborating with executive leadership to develop targets for program success.

  • Strategy: Drives the strategic leadership, guidance, and tactical direction for Enterprise Payment Integrity. Responsible for ensuring appropriate prioritization of solution development and service investments.

  • Coaching: Is a champion for the discipline of payment integrity practices, ensuring that teams have essential tools, processes, and skill sets to build out product and service roadmaps that align with BCBSMA’s strategic and operational plans.

  • Growth: Accountable for developing solutions that support operational efficiency and growth targets.

  • Program development: Works in tandem with cross-functional teams on all new development, and improvement of existing solutions in line with strategic development opportunities. Reviews program performance against expectations and facilitates or influences changes to program portfolio to improve competitive position and optimal program performance.

  • Quality: Works closely with technology, operations, and senior leadership to ensure releases are of the highest quality, and that his/her team can demonstrate progress against quality goals through clear metrics.

  • Leadership: Proactive leader with proven experience in strategic and tactical leadership with the ability to pursue and understand cutting edge technologies. An excellent “coach” who is results oriented and can build and motivate high performance teams.

Qualifications (knowledge/skills/abilities/behaviors):

  • Demonstrated expert level knowledge and understanding of the health care industry, specifically as it relates to the financing of healthcare services

  • Strong understanding of strategic and operational planning concepts and methodologies

  • Long-range planning skills and ability to integrate with short-term activities

  • Ability to effectively plan and facilitate organized and productive meetings/workgroups

  • Demonstrated leadership skills in team and/or group settings

  • Proven ability to effectively collaborate with many different levels within the organization

  • Ability to engender trust and confidence with a high sense of integrity and ethics

  • Develop and maintain effective working relationships and provide high quality service with key internal customers

  • Very strong communication and presentation delivery skills

  • Ability to think strategically and translate corporate goals into team strategies

  • High level of organizational astuteness, professionalism, and poise

  • Comfortable leadership presence

Education/Relevant Experience:

  • Bachelor’s Degree and/or RN Licensure is required

  • Clinical coding certification (CPC, CCS, CIC, COC, and/or CRC), Master’s Degree in Business Administration, Health Administration or other advanced degree strongly preferred

  • 4-6 years of experience managing and coaching others

  • 10+ years of experience in the health care industry

LocationBostonTime 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.