Manager, Provider Compliance

Healthy Careers Start Here

At Blue Cross & Blue Shield of Mississippi, we encourage professional growth in a challenging and fast-paced atmosphere. Our 'be healthy' culture promotes health and wellness at all levels of the Company, and we provide our employees with the time, tools and resources to commit to a healthy lifestyle.

The Manager, Provider Compliance is responsible for managing the Provider Compliance team in analysis, research, investigation and audits of providers and pharmacies to confirm compliance with Company contracts, policies, claims filing guidelines, and coding requirements, as well as review of providers suspected of fraudulent, wasteful or abusive activities. This position provides assistance to the Director, Legal Operations and General Counsel by identifying and implementing proactive measures to ensure providers and pharmacies are submitting appropriate coding for services performed, performing services which are medically necessary and which meet medical policy standards for utilization, and which are compliant with contractual obligations. The Manager, Provider Compliance also manages the Provider Compliance team in conducting Professional Provider credentialing reviews and implementing associated compliance-related processes in compliance with regulatory and accreditation requirements, as well as credentialing of pharmacy applicants for the Advanced Health Systems, Inc. Community PLUS Pharmacy Network. The position is responsible for managing staff in coordinating the audit activity of the Company’s third party audit vendor.

• Bachelor’s degree from an accredited university is required, with a degree in business or other degree which complements this position preferred.
• Management experience preferred.
• Three (3) years of audit experience required, with experience in auditing healthcare providers preferred.
• Experience in interpretation of data analysis and analytical reporting required.
• Excellent planning, problem solving, analytical and project management skills required.
• PC skills required to include the Microsoft Office Suite.
• Excellent verbal and written communications skills.
  
  

Blue Cross & Blue Shield of Mississippi is an Equal opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. We offer a comprehensive benefits package that is worth approximately one-third of the salary compensation. Our benefits program is among the best in the health care field. We are looking for employees who can bring their experience, expertise and dedication to work for our customers.