Payment Integrity Specialist

Job Description Summary: The Payment Integrity Specialist is responsible for ensuring invoicing and claims processing through BlueCard workflows are reviewed per established protocols for accurate and timely reconciliation for correct and complete payment(s).
The role incumbent is also accountable for auditing activities that capture, track, report, and validate claim savings and for alignment with established payment integrity invoicing practices.
Responsibilities may include development and documentation of protocols, processes, methodology application, and collaboration with internal partners as well as partnerships within other Blues Plans.
Job Description: JOB SUMMARY The Payment Integrity Specialist is responsible for ensuring invoicing and claims processing through BlueCard workflows are reviewed per established protocols for accurate and timely reconciliation for correct and complete payment(s).
The role incumbent is also accountable for auditing activities that capture, track, report, and validate claim savings and for alignment with established payment integrity invoicing practices.
Responsibilities may include development and documentation of protocols, processes, methodology application, and collaboration with internal partners as well as partnerships within other Blues Plans.
ESSENTIAL DUTIES & RESPONSIBILITIES Responsible for ongoing analysis of payments to providers for accuracy, completeness, timeliness, and any other necessary detail to ensure correct payment has been made.
Engages in active auditing activities of payments and claims to capture, track, report and validate claim savings in alignment with established payment integrity invoicing practices; ensures all claims savings are fully documented.
Professionally establishes collaborative relationships with other Blue Plans and acts as an effective liaison to facilitate inquiry response, claims pass-through, and the invoicing other Blue Plans for payment integrity services based on findings resulting from auditing activities.
Engages in research (may be in-depth and complex – some claims requiring research and audit may exceed 100+ lines) to resolve discovered past due invoices for validation; ensures resolution activities are based on findings and are fully documented.
Accountable for ongoing monitoring of claim financials enabling the necessary review, audit, track and validation activities; engages in routine follow-ups for all pending claims.
Ensures effective collaboration with internal partners regarding claims to ensure accurate and timely claim payment; internal partner relationships may include: Collaboration with finance regarding invoicing for payment(s) as well as dispute resolution and follow-up, Collaboration with Claims to ensure timely flow-through of provider claims, Collaboration with Members Services as needed regarding incoming inquiry (as may be relevant).
Accountable for utilizing problem-solving/troubleshooting methodologies to deep-dive into identified inaccuracies to ensure appropriate payment(s).
Actively engages in root-cause analysis for prevention as follow-up to problem-solving/troubleshooting to mitigate and/or eliminate future occurrence of similar issue whenever possible.
Accountable for consistent adherence to established procedures, processes, and protocols, as applicable for review, auditing, tracking, documentation, and problem-solving activities; utilizes pre-established templates, graphs, etc.
to best represent and report out activity aligned with expected cadence (e.
g.
, weekly, monthly, quarterly).
Engages in identification of potential process improvement for recommendation to leadership; implements process improvements with recommendation approval.
Accountable for professional representation of the Payment Integrity Department internally as well as in external relationships; example activities include providing data to update BCBSWY Board reports, as well as ASO reports.
Responsible for effective collaboration with the Blue Cross Blue Shield Association (BCBSA) in ongoing and future projects/initiatives such as the development of payment integrity invoicing rules and invoicing practices.
Professionally represents BCBSWY with the BCBSA as assigned/requested.
NON-ESSENTIAL DUTIES & RESPONSIBILITIES May be requested to support other Payment Integrity/Provider Relations team members as backup (cross-trained as needed) and serve as a training resource cross-departmentally when needed.
Assists Payment Integrity and Provider Relations leadership with projects, tasking, research, and the like, as may be assigned.
May be responsible for assisting in any internal/external audit processes that may touch payment integrity/provider relations as assigned.
APPLICABLE KNOWLEDGE, SKILLS, & ABILITIES (KSA) Knowledge of general accounting concepts.
Strong working knowledge of invoicing, invoice processing, and able to understand necessary level of detail.
Abilities utilizing problem-solving approach and collaboration for resolution.
Ability to analyze results of reconciliations and understand when follow up is required.
Ability to design and analyze data using spreadsheets and databases.
Knowledge of, ability to interpret, and consistently apply internal/organizational, as well as applicable external/regulatory policies.
Knowledgeable in accounting, auditing, and reconciliation to maintain accuracy.
Maintains contemporary knowledge of rules and laws which govern the payroll administration practices.
Proven capabilities of working with minimal supervision Ability to communicate clearly in written form.
Interpersonal communication skills and ability to work with others.
Proven skills with Microsoft Office Suite programs/applications (e.
g.
, Excel, Access, Word, Outlook, etc.
); specific skill levels of Basic with Excel including basic formulas, Intermediate with Word, and Basic business level skills with Outlook and Microsoft Teams.
Specific industry-related knowledge of BlueCard.
Skilled with establishing timelines and consistently meeting deadlines.
Able to select an appropriate method for processing various tasks/workflow items to ensure consistent high levels of accuracy.
QUALIFICATIONS Minimum of earned high school Diploma or GED required; relevant work experience may be considered in lieu of diploma.
Associate degree in Accounting, Business, Healthcare-related field or other similarly focused field of study preferred.
Minimum of 1 year of work experience in a role focusing on invoice processing, and/or billing processes required.
Previous experience within Healthcare, Medical Office processing, or general accounting preferred.
PHYSICAL/MENTAL DEMANDS & WORK ENVIRONMENT While performing the essential duties of this position, an employee will typically experience: Standing, walking, and sitting.
Lifting and/or moving up to 10 pounds; occasionally lifting and/or move up to 25 pounds short distances.
Usage of close vision, distance vision, and ability to adjust focus.
Manipulation of keyboards, keypads, and calculators.
Placing and answering telephone calls.
Focused task tracking and follow-through.
Some interpersonal tension in problem-solving/resolution interactions.
Speaking/presenting to internal and external audiences of diverse sizes.
Work environment noise level that is usually moderate.
Open office environment with few, if any, loud sounds, or ongoing auditory distractions.
Some deadline related stress.
As needed evening and weekend hours on a periodic basis.
Minimal travel, typically in-state.
To perform successfully in this position, an individual must be able to perform essential duties satisfactorily as well as possess education/experience, knowledge, skill, and abilities (KSA) as listed in representative fashion; reasonable accommodations may be made to enable individuals with limitations/disabilities to perform the essential functions of this position.
The essential duties and KSA listed are not all inclusive, but representative.
Other duties may be assigned.
Blue Cross Blue Shield of Wyoming is an EOE, M/F/Vet/Disabled employer.
Blue Cross Blue Shield of Wyoming uses E-Verify to confirm employment eligibility.
Equal Opportunity is the Law EEO is the Law Supplement IER Right to Work FMLA E-Verify Pay Transparency