Responsible foradministration of Blue Cross Blue Shield of Michigan professional, hospital outpatient, non-hospital facility reimbursement policy.
Responsible for identifying, collecting, analyzing, and maintaining data to evaluate issues that support prospective business decisions. Coordinate projects for senior management.
Research, analyze, identify, and evaluate data from assigned problems to evaluate existing and potential trends and issues.
Possess and maintain a comprehensive understanding and knowledge of BCBSM business, products, programs (including provider data, networks, etc.), corporate organizational structure (including functional responsibilities), and basic research principles/methodologies.
Assist in the management and monitoring of multiple projects simultaneously by establishing project plans and objectives to ensure goal attainment within defined parameters.
Communicate results of analysis to management via reports/presentations and assist management in implementing programs that provide solutions.
Recommend, communicate, and implement solutions to identified problems/root cause of issues.
Provide expertise and guidance to unit and corporate staff as required.
Represent and participate in group or committee discussions.
Departmental Specifics:
Reimbursement Administration Department is responsible for administration of reimbursement policy for professional and nonhospital facility providers. The effort involves updating professional fee schedules and non-hospital facility rate schedules, based on instructions and directions from the Reimbursement Policy Areas. Reimbursement Administration Department personnel calculate and load the updated fees/rates to the claims processing system master fee files. Additional duties include, but are not limited to:
Assist and support the planning, development and implementation of new reimbursement projects, which are Divisional and/or Corporate in scope.
Research, analyze and evaluate data and prepare cost impact estimates for various professional and facility fee/rate updates.
Provide interpretation of Medicare reimbursement policy and make recommendations for fees and rates.
Participate in systems testing, develop procedures/controls and provide recommendations for the ongoing improvement of the fee/rate update process. Assist personnel (both internal and external) by answering reimbursement questions.
Leadership responsibility to coordinate the development and implementation of programs and strategies to improve service to our customers.
Process Policy Change Requests (PCRs) that impact fee and rates.
Establish and maintain supportive documentation for all fees and rates loaded to claims processing systems and comply with all internal controls.
Departmental Requirements:
Proficient in MS Access (SQL), Excel and Word.
A flexible self-starter able to multi-task, adapt to rapidly shifting priorities, adjust work schedule and work with urgency to meet deadlines.
Professional and friendly personality.
Ability to work effectively both independently and within a team to execute plans that achieve business results.
Strong research and analytical skills, with strict attention to detail.
Ability to work closely with management and teammates to monitor and report on factors that may influence workflows and identify process improvement opportunities
Departmental Preferences:
General understanding of BCBSM business, products and programs.
Understanding of and experience with HCPCS/CPT coding and familiarity with medical terminology.
Experience in workgroups for implementation of corporate initiatives.
Familiarity with Medicare reimbursement.
" Qualifications"
Bachelor's Degree in Business Administration, Economics, Health Care, Information Systems, Statistics or other related field is required. Master's Degree in related field preferred.
Four (4) or more years of experience in related field required.
Strong communication skills are required to understand, interpret, and communicate ideas.
Strong knowledge and use of existing software packages (PowerPoint, Excel, Word, etc).
Working knowledge of data languages such as SAS or SQL.
Strong analytical, organizational, planning and problem solving skills.
Ability to effectively interface with employees at all levels.
Understand and apply statistical inference.
Other related skills and/or abilities may be required to perform this job.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
Equal Opportunity Employer–minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity
Please see job description for required skills.
