Mgr/Sr Manager, Payment and Coding Policy- Hybrid

Purpose of the job

Manage the day-to-day activities of the Payment and Coding Policy area within the Healthcare Value Advancement (HVA) department. Serve as the primary contact and resource for staff. Provide oversight, direction, development, problem resolution and leadership for the Team. Drive corporate payment strategy and coding policy that ensures appropriate, accurate and predictable provider reimbursement for Commercial, Medicare and FEP products. Ensure that payment and coding policies are properly maintained and integrated into claims processing systems and vendor solutions. Lead overall strategic direction and execution of coding updates, coding guidelines, industry standard coding practices, billing issues, and payment, taking into consideration possible business implications. Oversee development of strategic analyses that impact business decisions, improve efficiency and drive innovation. Transform data and analytics into meaningful and actionable information. Ensure strategic alignment between HealthCare Value Advancement (HVA) projects and the organization's broader goals. Integrate analytics strategy into the execution process, including program management, project controls, communications, and vendor oversight.

Qualifications

REQUIRED QUALIFICATIONS

Required Work Experience

• 5 years of experience in analytics and 5 years of experience working for a healthcare organization / health insurer (Level 1)

• 3 years of experience in supervisory/management role (Level 1)

• 10 years of experience in analytics and 10 years of experience working for a healthcare organization / health insurer (Level 2)

• 7 years of managerial experience (Level 2)

Required Education

• High-School Diploma or GEDin general field of study

Required Licenses

• N/A

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

• 15 years of experience in a healthcare analytics role for a health insurer on a team such as informatics, healthcare economics, or actuarial (All Levels)

• 5 years of managerial experience (Level 1)

• 10 years of managerial experience (Level 2)

• Experience developing provider reimbursement and financial impact analyses (All Levels)

• Experience supporting code editing solutions (All Levels)

• Experience working with medical coders and coding (All Levels)

Preferred Education

• Bachelor's degree in healthcare administrative, business, or related field of study

Preferred Licenses

• N/A

Preferred Certifications

• Professional Coder Certification Exam, along with completion of the medical field experience requirement, resulting in certification from a professional coding institute/organization.

ESSENTIAL job functions AND RESPONSIBILITIES

• Manage the day-to-day operations of the Payment and Coding Policy area by training and leading a team of Strategists and Coders. Guide staff by assisting them with defining and prioritizing projects.

• Develop and maintain all claim payment and coding policies for Commercial, Medicare and FEP products. Identify potential policy changes, compile impact analyses, and present recommendations to the appropriate work group for approvals.

• Ensure that payment and coding policies are properly maintained and integrated into claims processing systems. Work with staff to triage issues and submit change requests.

• Proactively review and identify potential revisions to existing payment and coding rules and methodologies for improved consistency, thoroughness, accuracy and appropriateness. Review CMS guidelines, other industry payment and coding standards, online reference material, coding-related publications, and training material as part of this process.

• Manage vendor relationships that provide primary code editing, secondary code editing or other related services. Track issues, submit change requests, and manage content releases for these vendor solutions.

• Explore, analyze, and implement opportunities for payment and coding policy changes that support appropriate payment goals, engaging with key business partners for final decisions.

• Transform data and analysis into meaningful and actionable information for a variety of customer segments and help end users interpret results and business implications.

• Work collaboratively with various business areas to provide data support, analysis, monitoring, trending, and reporting.

• Provide leadership and/or HVA representation on corporate committees, analyzing, interpreting, and communicating information in formats that facilitate decisions and actions.

• Actively manage multiple aspects of cross-functional projects, identifying and driving key business decisions and gathering support across multiple divisions.

• Work with provider network and marketing to develop payment and coding policy documentation for release to providers through a variety of channels (e.g. online, newsletters. etc.).

• Build and maintain effective working relationships with internal stakeholders and key external client contacts to ensure teamwork in achieving corporate goals. Manage informal relationships to get things done in the absence of direct reporting lines.

• Work with team leaders and management to vet, refine and prioritize new project ideas.

• Integrate HVA strategy into the execution process, including program management, project controls, communications, and vendor oversight.

• Research latest developments by governmental and industry entities on the establishment of payment and coding policies. Present findings and recommendations in written and verbal formats. Monitor external economic and healthcare issues affecting trends, preparing succinct, easy to understand presentations of results and conclusions.

• Communicate strategic initiatives and recommendations to various levels of senior management to support data-driven decision-making. Communicate (both verbally and in writing) and interpret results, recommendations, and abstract concepts to internal and external customers. Anticipate and addresses possible customer questions and concerns. Produce easy to understand presentations focused on business implications.

• Drive and execute complex and critical initiatives with minimal oversight.

• Develop multi-year strategies, priorities, and roadmap for HVA goals.

• Provide guidance, motivation, and encouragement to staff, conduct performance evaluations, identify, and coordinate training needs, and evaluate and make recommendations regarding employment decisions.

• Administer, interpret, and maintain current working knowledge of the required BCBSAZ systems, procedures, forms, and manuals as related to the assigned area of responsibility.

• Review, update and maintain accuracy of department documentation, computer files, policies and procedures related to the department goals and objectives. Keep staff informed of new or updated standards, systems, procedures, forms and manuals through staff meetings and verbal and written communications.

• Consult and coordinate with various internal departments, external Blue Plans or business partners and government agencies.

• Assist with and maintain budgetary department goals for the Payment and Coding Policy area.

• Demonstrate a strong business perspective, industry-knowledge, organizational skills and communication skills.

• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.

• Perform all other duties as assigned.