Payment Integrity Audit Consultant

What We Need

The Payment Integrity Audit Consultant role is responsible for high-impact initiatives that enhance the integrity of claims payments. In this role, you will leverage data mining and analytics to identify anomalies, trends, and recovery opportunities across claims systems. Your work will ensure compliance with BCBSMA Medical and Payment Policies, industry standards, and audit protocols while contributing to enterprise-wide cost containment and process improvement initiatives.

This role demands advanced technical expertise, strong business acumen, and a proactive approach to problem-solving. We're looking for an individual with a deep understanding of healthcare data, coding, and reimbursement practices-someone who brings critical thinking, and a continuous improvement mindset to the table.

Day-to-Day Responsibilities

• Manage high-visibility projects that analyze large volumes of claims data to detect patterns, coding discrepancies, and payment anomalies.
• Responsible for leading the design, execution, and oversight of the audit analysis to ensure the accuracy and appropriateness of claims payments.
• Translate audit insights into actionable recommendations and partner with cross-functional leaders to implement systemic solutions.
• Integrate data from multiple sources (e.g., NASCO, Cognos, CXT) to develop evidence-based recovery plans and identify areas for process optimization.
• Present data-driven findings and recovery opportunities to executive stakeholders and support strategic decision-making.
• Ensure all audits are compliant with relevant regulatory and internal standards, while continuously improving audit methodology.

What You Bring:

• BA/BS or equivalent related professional experience
• Industry certifications CPC, CCS, CPMA strongly preferred.
• Minimum of 5 years of related professional experience
• Strong technical knowledge of medical coding systems (ICD-10, CPT, HCPC) and reimbursement methodologies.
• Deep understanding of claims systems and audit platforms such as NASCO, Cognos, and CXT.
• Proven experience translating complex data into strategic business insights.
• Excellent communication and interpersonal skills, with a demonstrated ability to influence across departments and levels.
• Strong organizational, analytical, and critical thinking skills with a proactive and adaptable mindset.
• Experience with cross-functional initiatives and managing competing priorities in a fast-paced environment.

#LI-Hybrid

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.