Principal Business Operations Advisor

Job Description

Payment Integrity Ideation Lead - Drives the creation of new audit concepts, data models, and reimbursement policies to reduce over payments. They leverage AI, vendor intelligence, claims data, and policy analysis to generate new savings opportunities and shift post-pay claim rework to proactive, pre-pay claim accuracy.

Provides oversight and coordination of departmental strategic planning, business and workforce plan development, business relationship management, reporting, data and/or budget analysis and special projects as assigned.

• Create new recurring and ad-hoc concepts to identify cost avoidance/over payment opportunities using large data sets on multiple variables. Provide data, analysis and recommendations to management on all findings affecting payments; including policy, contract issues, provider errors, pricing, systems and claim processes.
• Integrate deep data analysis and modeling to analyze complex claims, medical records, and provider contracts.
• Focus on shifting efforts upstream to pre-pay to reduce provider abrasion, administrative costs, and the need for retrospective recovery.
• Provide expertise in change management and portfolio management to align with organizational goals.
• Work with internal stakeholders to make any necessary technical updates to the system, policies and procedures when necessary, as well as coordinate education to providers. Track and report progress of prospective and retrospective cost avoidance/over payment recoveries.

• Bachelor's degree or advanced degree (where required)
• 8+ years of experience in related field.
• In lieu of degree, 10+ years of experience in related field.
• Payment integrity experience in a large payer Data Mining organization.
• Deep knowledge of payment integrity, payment methodologies, healthcare claim lifecycle, reimbursement policies.
• Proven analytic expertise using Microsoft Excel and Access, database query capabilities, and ability to evaluate data at all levels of detail.
• Ability to identify patterns and anomalies in large datasets.
• Experience working with cross-functional areas to implement new audit strategies.
• Proven success identifying and implementing automation opportunities (audit/workflow).

• Experience with lean or Six Sigma.
• Experience with Facets data.

• Opportunity to work at the cutting edge of health care delivery with a team that is deeply invested in the community.
• Work-life balance, flexibility, and autonomy to do great work.
• Medical, dental, and vision coverage along with numerous health and wellness programs.
• Parental leave and support, as well as adoption and surrogacy assistance.
• Career development programs and tuition reimbursement for continued education.
• 401k match including an annual company contribution.

Our Hybrid Flex approach is built on presence with a purpose—giving you flexibility to work remotely with intentional in-person connection—to support a workplace that is flexible, connected, and future focused. In a Hybrid‑Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually with a few in‑office visits each year for meaningful moments that matter.

Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market‑price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus based on annual corporate goal achievement and individual performance, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

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