Payment Integrity Resolution Specialist II

Blue Cross of Idaho is looking for a Payment Resolution Specialist to acts as primary investigator for provider inquiries and appeals related to Supplier and Payment Integrity audits. The Payment Integrity Resolution Specialist will be evaluating appeal details, making determinations and communicating complex medical and reimbursement information to providers within contractual requirements and plan policy.

We are looking for a Payment Integrity Resolution Specialist with:

Level I:

3 years' health industry or related experience

Level II:

4 years' health industry or related experience

Licenses/Certifications: Recognized Coding Certification

What a day of a Payment Integrity Resolution Specialist looks like:

• Appeal Analysis: Perform a claim coding and processing history review considering medical policy, reimbursement policy, regulatory and legal requirements, as well as benefits and provider contracts.
• Maintain detailed notes and records as well as statistical tracking
• May serve as a liaison between Payment Integrity and other internal departments as well as suppliers
• Obtain additional information or documentation, as needed, to make appropriate business decisions.
• Engage with and educates providers regarding their fee schedules, claims processing, coding guidelines and contractual requirements.
• Interpret and align with business rules, policies, contracts, and supplier audit activities as well as payment integrity audits.
• Assist in resolution of complex claim issues.
• Facilitate cross departmental review of inquiries and appeals to ensure comprehensive responses.
• Identify and performs basic research on emerging issues and trends and reports to leadership.

Additional skills we are looking for:

• Adaptability
• A continuous improvement mindset
• Dedication to team success
• Demonstrated ability to build strategic work relationships and trust

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.