[Remote] Provider Education Program Manager - Payment Integrity

Note: The job is a remote job and is open to candidates in USA. Blue Cross NC is seeking a Provider Education Program Manager to design, implement, and manage a health plan provider education program. The role focuses on identifying and addressing billing patterns indicative of potential upcoding and requires collaboration with various teams to ensure compliance and improve provider billing practices.

Responsibilities

• Develop and maintain the health plan’s provider education program for coding, documentation, and billing integrity issues, with a focus on potential upcoding and other aberrant provider billing patterns
• Establish program workflows, referral criteria, outreach templates, monitoring schedules, escalation pathways, and reporting standards to support compliant and consistent operations
• Create standardized processes for provider identification, educational intervention, follow-up review, and referral to SIU when concerning behavior persists
• Analyze claims, coding, utilization, reimbursement, and provider billing data to identify outlier patterns, unusual coding distributions, trending variances, and potential upcoding concerns
• Conduct targeted reviews using CPT, HCPCS, ICD-10, modifier usage, and documentation-related indicators to determine whether provider billing patterns warrant education or further escalation
• Partner with payment integrity, analytics, and coding subject matter experts to validate findings, quantify impact, and prioritize outreach opportunities
• Draft and issue provider education letters that clearly describe identified billing concerns, applicable coding/documentation expectations, and recommended corrective actions. Comparable education-focused coding roles emphasize post-audit reports, findings summaries, and provider-facing education communications
• Conduct provider outreach calls and meetings to review findings, explain coding or documentation expectations, answer questions, and reinforce compliant billing practices
• Develop educational materials, job aids, presentations, and provider-specific feedback to support improved coding accuracy and billing compliance
• Perform quarterly and semiannual post-education monitoring to assess whether provider billing behavior changes after outreach and whether additional intervention is needed. While the exact monitoring cadence is program-specific, comparable audit/education roles include baseline, routine periodic, and focused follow-up reviews to track improvement
• Document measurable outcomes such as coding trend shifts, reduction in outlier behavior, education completion, and cases escalated for further review
• Develop and administer a formal referral process to SIU for providers whose billing patterns do not improve following education or whose behavior suggests potential fraud, waste, or abuse. SIU-related coding roles commonly support referrals by reviewing claims, records, and concerning billing patterns and preparing case summaries for investigative action
• Prepare referral summaries, supporting documentation, trend analyses, and case narratives for submission to SIU, Compliance, or legal/regulatory partners as appropriate

Skills

• 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
• CPC, CCS (Required)
• Strong knowledge of CPT, HCPCS, ICD-10, modifiers, documentation standards, reimbursement methodology, CMS guidance, and payer billing requirements
• CEMA, CPMA (Strongly Preferred)
• CPIP (Nice to have) or similar coding/compliance certification
• Experience in managed care, Medicare, Medicaid, Marketplace, or commercial health plan operations
• Experience with provider education, payment integrity vendor outputs, post-pay review, overpayment recovery, or FWA/SIU workflows
• Advanced Excel, dashboarding, and data visualization skills

Benefits

• Annual Incentive Bonus*
• 401(k) with employer match
• Paid Time Off (PTO)
• Competitive health benefits and wellness programs
• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match including an annual company contribution

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