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This position will be a member of the Payment Integrity team, to provide leadership, organization and direction for all medical aspects of the suite of payment integrity programs and services. This role will also provide direction and oversight in the development and implementation of new programs and rules including clinical and coding guidelines for Payment Integrity services. This role will represent payment integrity to vendor programs and serve as a liaison among internal departments, external customers and providers on payment integrity initiatives and audit results. The role will also help to develop effective, well-defined and supported processes and functions for purchaser populations, and will develop, in collaboration with the full payment integrity team, new programs and concept management to meet Payment Integrity goals.
A Day in the Life:- Perform medical director auditing of claims referrals for potential recoupment or denial, providing clear rational for decision
- Provide medical consultation and review of new concepts for potential waste and abuse
- Provide clinical leadership oversight to vendor products
- Develop and implement new coding and clinical programs and rules within payment integrity
- Consult with medical directors on new opportunities
- Participate in sales presentations and RFP's
- Spokesperson for Payment Integrity programs to external departments, providers, and other plans
Accepting this director level position at BCBSMN requires signing an Employee Confidentiality, Intellectual Property.
Assignment and Restrictive Covenants Agreement as a condition of employment.
- Board certification in Internal Medicine, Family Practice, General Surgery or appropriate area.
- Unencumbered license to practice medicine in Minnesota.
- At minimum, 5 years clinical experience plus 5 years administrative or managed care experience including utilization management and or payment integrity
- Demonstrated success in driving new business, account retention and customer satisfaction
- Proficient in leading discussions and public speaking with large and small groups
- A highly professional, approachable and engaging communication and work style that engenders trust, credibility and collegiality
- Demonstrated track record of utilizing data driven analysis to create actionable solutions
- Ability to understand metrics at granular levels and in-depth experience with data, health care economics and reporting
Blue Cross and Blue Shield of Minnesota is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.