Blue Cross and Blue Shield of Louisiana Jobs

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Blue Cross and Blue Shield of Louisiana Reimbursement Configuration Administrator (Analytics) in Baton Rouge, Louisiana

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Please note that effective Jan. 4, 2022, Blue Cross and Blue Shield of Louisiana will require any employee who enters any of our offices or who interacts in person with anyone for company business purposes to be fully vaccinated for COVID‑19, unless legally entitled to a reasonable accommodation related to religious or medical exemptions. Please note this is subject to change at any point in time to ensure compliance with company policy or government mandates.

Residency in or relocation to Louisiana is preferred for all positions.

POSITION PURPOSE

This position provides direction and leadership to the Institutional Reimbursement team and has overall accountability for the configuration, system implementation and maintenance of payment policies for institutional providers and related healthcare entities, Also, responsible for all operational functions related to the company’s institutional provider reimbursement methodologies and integrated systems, directing short-term and long-term strategic planning to configure and implement institutional reimbursement strategies and payment policies in concert with claim process system capabilities and related software. Establishes policy and process for the rate administration component of all institutional health care provider reimbursement in order to maintain fiscal compliance with provider contracts and to mitigate risk under internal and external audit, SAS 70, FEP, BCA, DOI and state and federal laws including PPACA. Ensures compliance with related BCA mandates.

NATURE AND SCOPE

  • This role does not manage people

  • Necessary Contacts: To do this job effectively the incumbent has to be in contact with:Network Administration Management, IT Management, Benefits Administration Management, Medical Management, Medical Coding, Payment Integrity, Business Engineering Team, Project Management Office, Blue Cross Association, other health plans and software vendors in order to successfully configure and implement new and innovative payment programs that support Healthcare Reform.

QUALIFICATIONS

Education

  • Bachelor's Degree in Accounting, Finance, Business Administration, Economics or Healthcare Administration required

  • MBA, MPH or CPA preferred

  • Four years of related experience can be used in lieu of a Bachelor’s degree.

Work Experience

  • 7 years of extensive experience in the healthcare finance industry including provider reimbursement, provider payments, complex provider contracts, medical coding, clinical editing, fee schedules and institutional reimbursement system implementation required

  • 2 years of leadership experience required in this discipline required

  • Experience in solving business, financial and clinical problems with the appropriate technologies and analytic methodologiesrequired

  • Experience in reimbursement methodology system implementation and testing required

Skills and Abilities

  • Must possess strong analytical skills, supported by equally strong critical thinking skills, and a comprehensive understanding of all aspects of healthcare financing and institutional reimbursement, including industry-wide (private and governmental) payment methodologies.

  • Must possess excellent oral and written communication skills including the demonstrated ability to present complex financial analysis to Management and facilitate internal strategic operational discussions.

  • Must have strong project management skills regarding project planning and implementation, including developing scope, goals, work plans, timelines, implementation strategies and measurement processes for assessing progress toward goals and project outcomes, and be able to direct and prioritize multiple projects.

  • Extensive knowledge of Microsoft Office products including Word, Excel (including Pivot Tables), Access (SQL is preferred) and Power Point. Work experience must demonstrate the ability to work proficiently in a fast-paced demanding environment.

  • Must be able to travel overnight two to four times a year.

Licenses and Certifications

  • Non Clinical\CPC and/or CCSP - Certified Professional Coder Medical coding designation such as CPC or CPHC 2 years preferred

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

  • Provide leadership and operational oversight for a team of reimbursement analyst who support corporate and divisional strategy and goals. Communicates strategy and initiatives to team members supporting achievement of overall company results.

  • Work closely with the Director, Facility Reimbursement and Payment Policy to continually refine, implement, and manage the reimbursement operations strategy, focusing on the efficient, compliant and cost effective use and configuration of the related integrated systems, and to align with the corporate and divisional strategies and initiatives.

  • Responsible for the configuration, implementation, maintenance and documentation of institutional provider payment algorithms into the operational environment for participating and non participating providers, to support all institutional provider reimbursement programs including: Per diems and DRG weight-based methods; Related DRG assignment and provider configuration software for claims processing and modeling; Outpatient APC weight based fee schedules and related software; and other customized methods in support of contractual commitments for institutional providers, including the clinical editing requirements and the application of medical policy.

  • Performance Standard:- Provide planning and oversight with Network Administration, IT, BET, Medical Management, Benefits Administration, and Customer/Provider Service to ensure that all institutional and ancillary provider payment and contracting updates and/or changes are appropriately implemented and administered for all networks and claim processing systems (local, FEP, ITS, EDI, and BMS).

    • Directs the research and resolution of all systems reimbursement/coding issues which are identified by various departments as a result of claims processing discrepancies. Performs audits and/or works with Payment Integrity to ensure that reimbursement provisions are applied according to contract specifications for new and existing reimbursement programs.
    • Provides clarification for all departmental or provider inquiries, regarding existing reimbursement coding methodologies.
    • Coordinate efforts with payment policy/editing vendors who support provider payment systems and opportunities/innovations. Assure that contractual requirements are documented and implemented in compliance with company and legal requirements. Lead implementations and updates.
    • Participate in a variety of process-improvement initiatives that enhance network payment and policy activities.
  • Coordinate efforts with the Medical Coding Department to incorporate quarterly and annual new medical code revisions into reimbursement systems and strategies. Ensure that all new CPT/HCPC codes, etc, are incorporated into all applicable reimbursement programs by the required dates to prevent the related provider claims from paying more than the appropriate, contracted reimbursement. Also ensure that the semi-annual fee updates for new CPT/HCPCS codes are implemented by the established deadlines.

  • Responsible for all activities associated with managing the rate update process, in Facets, and validation at the specific provider level, for all institutional providers, in accordance with BCBSLA provider contracts and non-member provider policy.

  • Performance standard:- Ensure that all reimbursement rates, revised methodologies and fee schedules are loaded for each institutional provider, by the stated effective date, for all applicable networks upon execution of new or revised contracts.

    • Ensure that the appropriate operational and audit processes are in place to ensure 100% accuracy for this process, given that the materiality of even minimal errors can result in millions of dollars in incorrect payments and thousands of claims requiring adjustments for local, FEP and ITS.
  • Support the ongoing development and configuration of the provider contract modeling software and integrated clinical groupers and editing software. Ensure that the institutional provider payment algorithms available and utilized in the modeling software are synchronized with the payment algorithms utilized for claims processing. Ensure that medical coding updates, new enhanced payment algorithms and vendor software updates coordinated timely for both the modeling and claim processing systems to ensure the payment of claims is consistent with projected impacts of contract revisions.

  • Ensure compliance with BCA mandates, DOI mandates, new applicable state and federal laws/regulations, and claims editing rules.

Additional Accountabilities and Essential Functions

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

  • Perform other job-related duties as assigned, within your scope of responsibilities.

  • Job duties are performed in a normal and clean office environment with normal noise levels.

  • Work is predominately done while standing or sitting.

  • The ability to comprehend, document, calculate, visualize, and analyze are required.

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An Equal Opportunity Employer

All BCBSLA EMPLOYEES please apply through Workday Careers.

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Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.

In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.

JOB CATEGORY: Data Analytics/Warehousing, & Business Intelligence

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