Bcbsa
Director, Payment Integrity
Chicago or Washington, D.C · Director
Sponsorship not specified$141k-$191kDetected 30 days ago
Machine LearningAuditingPerformance ManagementPublic HealthLeadershipCommunicationClaims Management
About the role
- 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.
Requirements
- Required BS or equivalent experience
- Knowledge Skills and Abilities
- Experience with matrix organizational navigation and ability to influence without direct authority.
- Experience with vendor selection, contracting, and performance management for payment integrity services.
- Program Management skills with a track record leading multi-year transformation initiatives with strong change management capabilities and vendor oversight.
- 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
- Required 12+ Years Progressive Experience in healthcare payment integrity and claims operations
- 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
- Background spanning commercial and government programs (Medicare Advantage, FEP).
- 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.
Nice to have
- Understanding of AI/ML applications in payment integrity preferred.
- Prior Blue Cross Blue Shield System experience preferred
Skills
- Oversee PI reporting for national accounts and ensure Plans are meeting established requirements.
- Advise on PI requirements and best practices for the FEP membership population
Compensation
- Experience managing programs with P&L impact of $100M+ annually.
Benefits
- Possesses a solutions-orientated mindset with a bias toward action with ability to balance strategic vision and operational pragmatism
This listing is sourced directly from Bcbsa's careers page and normalized into a canonical job model.