Payment Integrity: Reimbursement Policy Quality Assurance (QA) Analyst

Reporting to the Associate Director of Professional Reimbursement Strategy, the Payment Integrity Reimbursement Policy Quality Assurance (QA) Analyst is responsible for completing invoice and reconciliation claim audits for BCBSMA's payment integrity programs. Quality assurance audit reviews and core functions include reconciling vendor invoiced claims against finalized paid claims to identify and document payment discrepancies, root cause analysis to reduce errors, streamline audits, manage invoice database, interacting with stakeholders and producing reports for the programs.

The Payment Integrity Reimbursement Policy Quality Assurance (QA) Analyst would also be responsible for payment & reimbursement policy support including policy research & development, clinical editing, industry regulatory coding knowledge, business operations and acting as a subject matter expert (SME).

Key Functions

• Conduct comprehensive weekly/monthly/ad hoc invoice reconciliation QA audits for BCBSMA's payment integrity programs.
• Audit vendor claims data and invoices against plan enterprise warehouse claims data. Research and document audit and reconciliation findings and provide results on specific issues. Collaborate with internal and external stakeholders to resolve discrepancies, variances and account chargebacks.
• Process vendor invoice payments: including but not limited to creating payment request, obtaining leadership signoff and circulating final invoice and payment requests to impacted areas.
• Manage vendor invoice/reconciliation database as the truth source for all vendor invoices and produce reports to include claim reconciliation activity, savings, variances and vendor/account fee reports.
• Identify and implement opportunities for process improvement through root cause analysis and findings during the audit process that will promote effective and efficient solutions, enhance quality results, generate positive change, and mitigate risk.
• Support with payment & reimbursement policy and payment integrity activities including new/revising payment policies, proposals, assessing operational impacts, inquiries and implementation efforts.
• Support with all clinical editing inquiries, software update, QA/UAT, system updates, documentation and change requests.
• Ability to work independently to resolve issues and escalate appropriately
• Facilitate meetings and workgroups to improve performance and quality results

Required Education/Relevant Experience:

• BS/BA degree preferred or equivalent experience or training
• Minimum of 5 years claims audit/quality assurance experience in healthcare required
• Strong understanding of professional and facility healthcare payment and reimbursement policy
• Experience in working with claims editing software and payment integrity programs
• Certified Professional Coder (CPC) and certified outpatient coder (COC) preferred, experience with CPT/HCPCS & ICD10 coding, Correct Coding guidelines.
• Experience with MS Access, Cognos Power BI database program and excel
• Proficiency in working with and analyzing claims data
• Strong written and verbal communication skills
• Strong critical thinking & problem-solving skills
• Ability to manage competing priorities

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.