Payment Integrity: Reimbursement Policy Quality Assurance (QA) Analyst

Blue Cross and Blue Shield of Massachusetts, Inc.; Golden Horseshoe; On-site; USD 87,000 - 107,000; Full time

Job summary

An established industry player is seeking a detail-oriented Payment Integrity Reimbursement Policy QA Analyst. In this pivotal role, you will conduct audits and reconcile claims to ensure payment accuracy while collaborating with stakeholders to resolve discrepancies. Your expertise in healthcare payment policies and claims auditing will be essential in enhancing quality and mitigating risks. This position offers an opportunity to contribute to the development of reimbursement policies and improve operational efficiency within a dynamic environment. If you are passionate about quality assurance in healthcare, this is the perfect role for you.

Qualifications

• 5+ years of claims audit/quality assurance experience in healthcare.
• Strong understanding of healthcare payment and reimbursement policies.

Responsibilities

• Conduct QA audits for payment integrity programs and reconcile claims.
• Manage vendor invoice database and produce reports on reconciliation.

Skills

Claims Audit

Quality Assurance

Healthcare Payment Policies

Analytical Skills

Communication Skills

Problem-Solving Skills

Education

BS/BA Degree

High School Diploma

Tools

MS Access

Cognos Power BI

Excel

Claims Editing Software

Job description

Reporting to the Associate Director of Professional Reimbursement Strategy, the Payment Integrity Reimbursement Policy Quality Assurance (QA) Analyst is responsible for completing invoice and reconciliation claim audits for BCBSMA's payment integrity programs. Core functions include reconciling vendor invoiced claims against finalized paid claims to identify and document payment discrepancies, conducting root cause analysis to reduce errors, streamlining audits, managing the invoice database, interacting with stakeholders, and producing reports.

The QA Analyst also supports payment & reimbursement policies, including policy research & development, clinical editing, industry regulatory coding knowledge, business operations, and acting as a subject matter expert (SME).

Key Functions

1. Conduct weekly/monthly/ad hoc invoice reconciliation QA audits for BCBSMA's payment integrity programs.
2. Audit vendor claims data and invoices against plan enterprise warehouse claims data. Research and document audit findings, collaborate with stakeholders to resolve discrepancies, variances, and account chargebacks.
3. Process vendor invoice payments, including creating payment requests, obtaining leadership signoff, and circulating final invoices and payment requests.
4. Manage vendor invoice/reconciliation database as the authoritative source, produce reports on claim reconciliation activity, savings, variances, and vendor/account fees.
5. Identify and implement process improvements through root cause analysis to promote effective solutions, enhance quality, generate positive change, and mitigate risks.
6. Support payment & reimbursement policy activities, including developing new/revising existing policies, proposals, operational impact assessments, and implementation.
7. Assist with clinical editing inquiries, software updates, QA/UAT, system updates, documentation, and change requests.
8. Work independently to resolve issues and escalate as needed.
9. Facilitate meetings and workgroups to improve performance and quality results.

Required Education/Experience

• BS/BA degree preferred or equivalent experience or training.
• Minimum of 5 years claims audit/quality assurance experience in healthcare.
• Strong understanding of healthcare payment and reimbursement policies.
• Experience with claims editing software and payment integrity programs.
• Certified Professional Coder (CPC) and outpatient coder (COC) preferred, with CPT/HCPCS & ICD10 coding experience.
• Proficiency in MS Access, Cognos Power BI, and Excel.
• Strong analytical, communication, and problem-solving skills.
• Ability to manage competing priorities.

Minimum Education Requirements

High school diploma or equivalent required unless otherwise noted.

Location

Boston

Time Type

Full-time

Salary Range

$87,030.00 - $106,370.00