Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
The position will be focused on identifying and recovering overpayments resulting from errors, waste, and abuse while strategically developing and implementing plans to shift effective post-payment controls to pre-payment. This role will lead efforts related to data mining, contract compliance as well as the development of industry standard reimbursement policies. A key focus will be internalizing vendor-driven payment integrity functions to enhance controls and reduce costs.
Responsibilities:
Hospital Billing:. Leverage extensive experience in hospital billing and revenue cycle management to analyze complex post-adjudication and potential pre-adjudication hospital claims, identify coding errors, and ensure accurate overpayment recovery and prevention.
Payment Integrity Model: Design and implement robust pre and post-payment review programs, including audits, data mining, and recovery processes, with a particular emphasis on hospital claims. Regularly assess the feasibility and economic impact of internalizing Payment Integrity activity conducted by Horizon’s vendor partners.
Pre-Payment Transition Planning: Develop and execute plans to strategically move effective post-payment controls and identification processes to pre-payment, minimizing future overpayments
Vendor Processes: Analyze current vendor-driven payment integrity functions and develop plans to internalize these processes, improving control, reducing costs, and building internal expertise
Data Analysis & Reporting: Utilize data analytics and reporting tools to identify trends, patterns, and risk areas related to both post-payment and potential pre-payment errors, waste, and abuse, leading data mining efforts to uncover payment irregularities.
Performance Monitoring: Establish and monitor key performance indicators (KPIs) focused on recovery rates, accuracy of overpayment identification, efficiency of post-payment processes, successful transition to pre-payment controls, and contract compliance. Collaborate with internal departments, including claims, provider network, legal, and compliance, to address payment integrity issues, implement corrective actions, and facilitate the transition to pre-payment controls.
Benchmarking: Stay abreast of industry trends, best practices, and regulatory changes related to payment integrity, including both post-payment recovery and pre-payment prevention strategies.
Education/Experience:
High School Diploma/GED required.
Bachelor degree in Healthcare Administration, Business Administration, or Finance preferred or relevant experience in lieu of degree.
Master’s Degree preferred.
Requires a minimum of 5 years of progressive experience in payment integrity, healthcare, finance or revenue cycle management with a significant focus on hospital billing including claim auditing and editing field or relevant field.
Requires minimum of 3 years’ experience in project implementation.
Strong experience with data analytics, reporting tools, and financial testing processes.
Requires experience in health insurance industry.
Additional licensing, certifications, registrations:
Knowledge:
Health insurance products, insurance terminology, health plan operations.
Regulatory environment, state specific laws, mandates and regulations. six sigma, process redesign and project management methodologies.
Strong ability to apply structure to loosely defined medium to complex problems.
Broad knowledge of IT concepts, disciplines, best practices and methodologies.
Stay abreast of industry trends, best practices, and regulatory changes related to payment integrity, including both post-payment recovery and pre-payment prevention strategies.
Skills and Abilities:
Extensive experience in hospital billing and revenue cycle management is mandatory.
Requires vendor management experience in payment integrity.
Strong analytical and problem-solving skills, with the ability to interpret complex data and identify trends in both post-payment and potential pre-payment claims.
Excellent communication and presentation skills, with the ability to effectively communicate with internal and external stakeholders, including providers during recovery processes.
Knowledge of healthcare regulations, including HIPAA, Medicare, and Medicaid, focusing on overpayment recovery and pre-payment prevention regulations.
Proficiency in data analytics tools and software, medical terminology, medical coding (CPT4, ICD9 or ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Salary Range:
$96,300 - $131,565
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
