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About the Role:
Reporting to the Director of Professional Reimbursement Strategy, the Payment Policy Sr. Specialist serves as a trusted subject matter expert on professional provider payments, claims reimbursement integrity, and fee schedule administration. Operating as part of a high-impact, collaborative team, this role is critical to advancing BCBSMA’s core strategic objective of healthcare affordability and payment transparency. You will bridge clinical coding principles, payment policy formulation, claims data analytics, and vendor partnerships to ensure provider payments accurately reflect contract terms and regulatory guidelines.
This role is eligible for the following personas: Flex (2 days per week on-site in Boston or Hingham, MA, on designated collaboration days).
Your Day to Day:
1. Payment Policy Formulation & Governance: Lead the development, drafting, review, and operational implementation of new and revised professional payment policies. Evaluate clinical coding guidelines, state and federal billing regulations, and provider contract structures to align claims adjudication with intended reimbursement practices.
2. Claim Editing Logic & Reimbursement Controls: Design, evaluate, test, and maintain claim editing rule logic across enterprise claims adjudication systems. Partner closely with IT and operational systems teams to translate reimbursement strategies into automated pre-payment and post-payment billing rules that eliminate improper or duplicative claim spending.
3. Fee Schedule Oversight & Pricing Maintenance: Oversee and maintain professional fee schedules and drug reimbursement schedules. Evaluate, model, and price new and existing CPT, HCPCS, and ICD-10 codes, ensuring timely system loads, regulatory compliance, and alignment with corporate trend management objectives.
4. Claims Analytics & Financial Trend Modeling: Analyze comprehensive claims data against provider reimbursement methodologies and industry benchmarks. Assess financial, operational, and network impacts to quantify medical cost savings, uncover emerging payment integrity opportunities, and deliver data-driven recommendations to leadership.
5. Vendor Management & Strategic Inquiry Triage: Manage and expand pre-payment integrity vendor programs, including identifying prospective vendor solutions, evaluating technical capabilities, supporting contract negotiations, and monitoring service deliverables. Serve as primary SME to triage, investigate, and resolve complex inquiries submitted to the professional reimbursement inquiry mailbox.
This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.
This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.
We’re Looking For:
• In-depth knowledge of professional coding conventions and guidelines including CPT, HCPCS Level II, ICD-10-CM, CMS Correct Coding Initiatives (CCI), National Correct Coding edits (NCCI), and CMS-1500 billing instructions.
• Demonstrated hands-on experience evaluating, writing, or managing rule logic within commercial claims editing and payment integrity software engines (e.g., Lyric/ClaimsXten, Optum/CES, Cotiviti, or proprietary claims adjudication systems).
• Proven capability to query, manipulate, and analyze large-scale healthcare claims data sets using Excel (advanced formulas, pivot tables, modeling) and analytical database tools to measure financial variance and ROI.
• Experience managing third-party payment integrity vendors, reviewing statement-of-work deliverables, and collaborating across cross-functional teams including Actuarial, Network Management, IT, Clinical Operations, and Legal/Regulatory…