About Blue Cross Blue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We’re committed to reinventing health care to improve health for our members and the community. We hope you'll join us.
How Is This Role Important to Our Work?
This position is responsible for providing leadership direction and oversight of reimbursement policy implementation to ensure policies are integrated with all systems and accurate claims processing. This includes managing coding research, policy coding, system configuration, policy databases, data reporting, and communication for policy implementation. The scope of accountability for Reimbursement Policy includes commercial and government programs lines of business.
A Day in the Life:
- Works closely with leadership to set the overall strategic direction for Reimbursement Policy and is responsible for: managing coding research and policy coding process; system configuration processes; policy databases and data reporting processes; policy databases, data reporting processes; policy research, development, and maintenance processes; the committee processes that support approval; the coverage determination process; policy communication; and policy training.
- Provide input on policy implementation to key policy committees and workgroups such as: Reimbursement Policy Prep Workgroups, Medical and Behavioral Health Policy Committee, Medical Pharmacy & Therapeutics Committee, Reimbursement Policy Committee, and Coverage Committee, Ethics & Compliance Regulatory Advisory Panel (RAP), and additional workgroups as needed.
- Oversee final policy documents and tools for implementation.
- Manage policy research & implementation and system integration to ensure accurate claims processing.
- Produce standard reports and assist in the analysis and impact of these reports as they relate to policy management.
- Participates in Blue Cross efforts to respond to regulatory and accreditation requirements (e.g., NCQA).
- Serve as a liaison to other divisions (e.g., Network Management, Account Management, and Service) for policy issues.
- Manage policy implementation-related projects within the division and across the organization, and lead workgroups as needed.
- Serve as a subject matter expert on policy research implementation for team members and other areas within Blue Cross.
- Leads the Reimbursement Policy team, including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive proper training.
- Conducts performance reviews and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations, and cost control.
- Researches and analyzes scientific literature and medical policies on a clinical topic to develop an organized, strategic approach, considering business integration in the policy development process
Required Skills and Experiences:
- 8+ years of related professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
- Knowledge of the managed care and health care/insurance industry.
- Strong, demonstrated leadership and communication skills.
- Demonstrated ability in developing and implementing strategic initiatives.
- Demonstrated ability to collaborate with and influence others.
- Proven ability to exercise good judgment, make independent decisions, and set priorities with minimal direction.
- Demonstrated knowledge, skills, and abilities in a leadership role.
- Critical thinking skills with proven ability to identify and implement process improvements.
- Effective verbal and written communication skills
- In depth understanding of medical claims and coding (CPT, HCPCS, ICD-10).
- Strong PC skills, including Excel, PowerPoint, Word, and web-based programs.
- Ability to develop and work on several projects at one time in a fast-paced environment.
- Project management experience.
Nice to Have:
- Bachelor's degree.
- Master’s degree in a clinical or health-related field.
- Work experience in a health care environment.
- Previous utilization management or medical policy experience.
- Knowledge, training, and experience in designing, executing, and analyzing data reports using member, provider, and claims data reporting systems.
- Claims adjudication and/or experience as a technical resource, with expertise in operational processes.
Make A Difference Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, gender expression, or any other legally protected characteristic.
Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to talent.acquisition@bluecrossmn.com.
All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S.
Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
