Director, Integrity - Coordination of and Data Mining

Job Description

Direct, manage and lead highly complex functional and/or broad foundational business areas within Payment Integrity to define and enable strategic and operational priorities. Lead and set goals for teams responsible for identifying, coordinating, and implementing initiatives/projects and activities that create efficiencies, optimize systems & processes, promote quality, and maximize medical and administrative expense savings. Teams may include Payment Integrity strategy and growth, operations, payment integrity clinical and specialty programs, and/or multiple payment integrity services either performed by vendors or internally.

• People leadership
• Resource management
• Project planning and management
• Financial and data analysis

• Provide leadership, vision, and direction for assigned teams.
• Direct staff of subject matter experts and analysts to identify & execute growth business initiatives, while managing existing programs: production problem resolution, system enhancements, and configurations.
• Accountable to define and execute strategy to deliver year-over-year growth and achieve savings target(s) within the COB and Data Mining vertical.
• Ensure business plans and industry analysis, consider future needs and drive "best in-class" thinking. Builds understanding of market trends and customer needs.
• Identifies new operational initiatives and modifications to current programs and processes to improve the company's competitive position/increase medical expense savings.
• Demonstrates understanding of the financial levers that impact business performance and deploys them to improve short- and long-term results.
• Lead and oversee management and delivery of enterprise and departmental projects including business case development, ROI analysis, planning, business analysis, and project management.
• Lead and oversee optimization of existing systems, processes, and workflows.
• Ensure programs and operations are performing successfully and are compliant in accordance with regulations of State, Federal, and other governing bodies; ensures corrective action plans are implemented when applicable.
• Develop internal PI Provider Education program to enhance provider experience and focus on change in behavior.

• Bachelor's Degree
• 10 years of experience managing multifunctional payment integrity teams
• In lieu of bachelor's degree, 12 years of experience as stated above
• Must have direct health plan experience
• 7 years leadership experience

• Extensive knowledge of coordination of benefit primacy rules for commercial and Medicare lines of business, including knowledge of MSP demand process
• Basic claim coding knowledge for better understanding of data mining concepts
• Experience with project and software life cycle management
• Experience with vendor management from an operational perspective
• Experience with vendor contract negotiations
• Understanding of claims adjudication systems and pricing configuration and architecture
• Coding and billing experience

• The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community
• Work-life balance, flexibility, and the autonomy to do great work
• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match including an annual company contribution
• Learn more

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.

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