Analysis Skills, Auditing, Behavioral Health, Change Control, Claims Processing, Consulting, Continuous Improvement, Cross-Functional, Documentation Standards, Electronic Data Interchange (EDI), Healthcare, Healthcare Providers, Healthcare Quality, Leadership, Managed Care, Policy Development, Problem Solving Skills, Procedure Development, Process Improvement, Project/Program Management, Provider Contracting, Public/Media/Press/Analyst Relations, Regulations, Reporting Skills, Root Cause Analysis, Trend Analysis, Vendor/Supplier Relations
Your Role
The Behavioral Health Network Management, Healthcare Quality and Affordability (HQA) team is responsible for the development and maintenance of all Behavioral Health provider networks, including vendor relationships necessary to provide our members and clients with access to quality, affordable health care services. The Program Manager, Consultant will report to the Program Manager, Principal. In this role you will support the Behavioral Health Network Management, HQA team and be responsible for investigating and resolving claims issues through detailed root cause analysis, cross functional collaboration, and end to end remediation oversight.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Knowledge and Experience
- Requires a Bachelor's degree or equivalent experience
- Requires 7 years of prior relevant experience in Medicare claims processing and regulatory requirements; working with regulatory Behavioral Health (BH) requirements, audit readiness, documentation standards; BH claims analysis, issue investigation, and remediation oversight
- Requires Project Management experience
- Behavioral Health (BH) managed care experience of 5 years is preferred
- Experience with regulatory BH claims audits is preferred
- Experience researching BH claims for overpayments and fraud is preferred
- Experience with BH Policy & procedure development and auditing is preferred
- Knowledge of fundamentals of BH provider contracts
Hybrid
This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.
Your Work
In this role, you will:
- Operate at a strategic business level to ensure projects/programs are in line with Blue Shield of California (BSC) strategic goals
- Consult with all levels including executive leadership teams, make recommendations, and influence decision-making
- Leverage cross-functional internal and external relationships to drive initiatives forward
- Lead intake, investigation, and resolution of complex Behavioral Health (BH) provider-reported claims issues, including escalations and system enhancement
- Perform detailed root cause analysis of claim processing issues, partnering with Claims Operations, Configuration, Provider Operations, EDI, and other teams to identify underlying drivers
- Manage project initiatives from initiation through delivery and oversight for continuous improvement
- Identify patterns and trends in BH claims issues to inform process improvements, configuration changes, and control enhancements to prevent recurrence
Your Work
In this role, you will:
- Operate at a strategic business level to ensure projects/programs are in line with Blue Shield of California (BSC) strategic goals
- Consult with all levels including executive leadership teams, make recommendations, and influence decision-making
- Leverage cross-functional internal and external relationships to drive initiatives forward
- Lead intake, investigation, and resolution of complex Behavioral Health (BH) provider-reported claims issues, including escalations and system enhancement
- Perform detailed root cause analysis of claim processing issues, partnering with Claims Operations, Configuration, Provider Operations, EDI, and other teams to identify underlying drivers
- Manage project initiatives from initiation through delivery and oversight for continuous improvement
- Identify patterns and trends in BH claims issues to inform process improvements, configuration changes, and control enhancements to prevent recurrence
B
Blue Cross and Blue Shield Association
At the Blue Cross and Blue Shield Association (BCBSA), we provide business strategy, technical support and consulting expertise to 36 Blue Cross and Blue Shield companies across the nation, employing more than 1,000 of the best strategic thinkers in the industry. We are a Brand manager that sets quality control standards for the 36 independent companies that use the Blue Cross and Blue Shield Brands, and we serve as a trade association that represents these Blue companies. It is through our involvement that the Blues companies share a united vision and strategy while also benefiting from the local strength of all member companies.
2,000 to 2,499 employees
https://www.bcbs.com/about-us/careers