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Claim Payment Policy Lead job in Philadelphia at Blue Cross and Blue Shield Association

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Claim Payment Policy Lead at Blue Cross and Blue Shield Association

Claim Payment Policy Lead

Blue Cross and Blue Shield Association Philadelphia, PA (On Site) Full-Time
Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals. If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole-person health.


The Claim Payment Policy Lead is responsible for developing and maintaining complex claim payment policies that reflect nationally recognized reimbursement practices and explain Company programs. Provides day to day leadership for the Claim Payment Policy team in the development, application of medical codes and development of business requirements to support policy enforcement. Oversees the Company's quarterly code update process, as well as incident/inquiry research and resolution for claim payment policy matters. Leads the Claim Payment Policy Advisory Committee and participates and/or leads other projects and workgroups as necessary. Develops key reporting measures and develops business cases to support decision making.


* Develops and maintains complex claim payment policies conforming to accepted standards and in accordance with Company benefit structure, state and federal mandates and other appropriate sources.
* Oversees the Quarterly Code Update Process and Master Grid Creation. Involves monitoring governing entities for medical code set changes. Identifies all Medical& Claim Payment Policy impacts, organizes/facilitates interdepartmental meetings to ensure policies and business requirements are updated accordingly. Determines all new code HCCS attributes allowing for accurate claim processing outcomes and delivers to vendor for setup. Creates and distributes Quarterly Master Grid within the Company to communicate established coverage positions and HCCS attributes.
* Orients new staff, serves as a mentor and provides oversight of assignments and projects of other policy staff.
* Convenes multidisciplinary meetings, workgroups or expert panels to resolve complex issues as required.
* Provides management with all required tracking data and productivity reports.
* Maintains departmental resources used in policy development activities.
* Routinely facilitates standing departmental meetings.
* Develops and maintains departmental policies and procedures.
* Recommends and implements departmental process efficiencies.
* Maintains detailed knowledge of the status of all projects and routinely updates management as appropriate.
* Serves as a liaison to other departments of the Company and represents the department at meetings and on work groups as assigned by management.
* Interacts with all levels of management within the Company and with outside contractors, consultants, and other organizations.
* Performs additional related duties as assigned.


* Bachelor's degree in in business, economics, finance, statistics, or equivalent work experience.
* More than six years related work experience.
* Knowledge of managed care products and claims processing systems.
* Demonstrated proficiency working with Microsoft Excel, PowerPoint and other tools.
* Exceptional written communication skills.
* Self-motivated, highly organized and detail oriented as well as above average problem solving, analytical and verbal and written communication skills.
* Demonstrated leadership ability including the ability to develop and lead cross-functional teams.
* Demonstrated ability to work in a team environment, be adaptable, and learn new tasks/functions quickly.
* Must be able to work independently, prioritize workload, meet deadlines, and to assess the criticality of issues.

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Job ID: 2345375016

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