Director, Payment Integrity

The Director, Payment Integrity serves as BCBSA's enterprise leader for advancing a System-wide payment integrity strategy that strengthens affordability across the Blue Cross Blue Shield System. This role is responsible for scoping, planning, and driving strategic PI initiatives in close partnership with BCBSA business leaders for Commercial Markets, Government Markets, and FEP, as well as BCBS Plan PI and business leaders. The role brings deep subject matter expertise, executive presence, and a solutions-oriented mindset to ensure the Blues remain competitive across all lines of business in their payment integrity capabilities.

BlueCard Payment Integrity Program

• Serve as the business owner for BCBSA’s effort to integrate payment integrity into BlueCard claims processing a significant and complex initiative spanning strategy through operations.
• Lead the scoping and design effort to define what PI within BlueCard needs to look like.
• Drive the operationalization strategy, including Plan engagement and change management across the System.
• Own the build-out and eventual ongoing management of BlueCard PI operations at BCBSA.

National Accounts Payment Integrity

• Serve as the accountable leader for ensuring the Blue System meets the payment integrity needs of national accounts, with a focus on hosted PI requirements and performance.
• Identify gaps in the current National Account space to develop future state roadmap.
• Define and maintain PI capability requirements for BCBS Plans in support of hosted national account business.
• Oversee PI reporting for national accounts and ensure Plans are meeting established requirements.
• Serve as a thought partner and System navigator when new PI challenges emerge, helping to formulate the Blue System’s response given its unique construct (e.g., developing the System’s approach to audit vendor activity)

Government Markets — FEP Medicare Advantage Wrap

• Serve as the PI subject matter expert advising Government Markets as it stands up the FEP Medicare Advantage wrap product and associated PI capabilities.
• Advise on PI operational requirements, program design, and best practices as the product is developed.
• Ensure appropriate PI controls and standards are embedded from the outset support government Markets leaders in building a sustainable PI framework for this new line of business FEP Payment Integrity.
• Partner with FEP leadership as a PI subject matter expert, with a focus on performance monitoring and continuous improvement.
• Advise on PI requirements and best practices for the FEP membership population
• Establish monitoring of PI performance and drive results over time
• Identify and recommend Plan specific along with National FEP improvement opportunities as the program matures.
• Partner with contracted pharmacy vendor(s) in support of FEP Commercial and EGWP lines of business, ensuring appropriate reporting to OPM and CMS.
  Payment Integrity Leadership
• Lead the Payment Integrity workgroup to align the Blue System around shared PI priorities and capabilities.
• Facilitate strategic planning, information sharing, and consensus-building across Plans and BCBSA stakeholders.
• Evaluate emerging market trends and translate them into actionable System-wide recommendations.
• Partner with the Segment Positioning team on strategic issues and market trends to ensure PI priorities are reflected in broader Blue System strategy
  Represent BCBSA in industry forums and keep pace with the evolving PI landscape.

The posting range for this position is:

141,270.37 - 191,046.72

Qualifications:
Education

• Required BS or equivalent experience; in Business Administration, Healthcare Administration, Finance or related field.; or equivalent experience
• Preferred MS or MBA in Healthcare Administration, Public Health or Business Analytics

Experience

• Required 12+ Years Progressive Experience in healthcare payment integrity and claims operations

Knowledge Skills and Abilities

• Payment Integrity Expertise including deep knowledge of PI methodologies (prepay/post-pay edits, audits, fraud detection, COB, Subrogation, DRG Auditing, Overpayment Recoveries, Clinical Coding, Claims Analysis), claims adjudication systems, and controls across Commercial, Medicare Advantage, and FEP lines of business.
• Demonstrated success leading complex, multi-stakeholder initiatives across distributed organizations
• Experience managing programs with P&L impact of $100M+ annually.
• Experience building operational capabilities from concept through execution
• Experience with matrix organizational navigation and ability to influence without direct authority.
• Background spanning commercial and government programs (Medicare Advantage, FEP).
• Experience with vendor selection, contracting, and performance management for payment integrity services.
• Strategic & Business Acumen with the ability to scope ambiguous enterprise initiatives, build business cases with ROI analysis, and translate operational complexity into executive strategy.
• Strong data & analytics background with the ability to leverage data for program design and performance measurement. Understanding of AI/ML applications in payment integrity preferred.
• Program Management skills with a track record leading multi-year transformation initiatives with strong change management capabilities and vendor oversight.
• Exceptional executive communication skills equipped to present to senior leaders, facilitate strategic discussions, and serve as trusted advisor to business unit heads.
• Possesses a solutions-orientated mindset with a bias toward action with ability to balance strategic vision and operational pragmatism
• Prior Blue Cross Blue Shield System experience preferred

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