[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.ResponsibilitiesDevelop 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 patternsEstablish program workflows, referral criteria, outreach templates, monitoring schedules, escalation pathways, and reporting standards to support compliant and consistent operationsCreate standardized processes for provider identification, educational intervention, follow-up review, and referral to SIU when concerning behavior persistsAnalyze claims, coding, utilization, reimbursement, and provider billing data to identify outlier patterns, unusual coding distributions, trending variances, and potential upcoding concernsConduct targeted reviews using CPT, HCPCS, ICD-10, modifier usage, and documentation-related indicators to determine whether provider billing patterns warrant education or further escalationPartner with payment integrity, analytics, and coding subject matter experts to validate findings, quantify impact, and prioritize outreach opportunitiesDraft 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 communicationsConduct provider outreach calls and meetings to review findings, explain coding or documentation expectations, answer questions, and reinforce compliant billing practicesDevelop educational materials, job aids, presentations, and provider-specific feedback to support improved coding accuracy and billing compliancePerform 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 improvementDocument measurable outcomes such as coding trend shifts, reduction in outlier behavior, education completion, and cases escalated for further reviewDevelop 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 actionPrepare referral summaries, supporting documentation, trend analyses, and case narratives for submission to SIU, Compliance, or legal/regulatory partners as appropriateSkillsBachelor's degree or advanced degree (where required)8+ years of experience in related fieldIn lieu of degree, 10+ years of experience in related fieldCPC, CCS (Required)Strong knowledge of CPT, HCPCS, ICD-10, modifiers, documentation standards, reimbursement methodology, CMS guidance, and payer billing requirementsCEMA, CPMA (Strongly Preferred)CPIP (Nice to have) or similar coding/compliance certificationExperience in managed care, Medicare, Medicaid, Marketplace, or commercial health plan operationsExperience with provider education, payment integrity vendor outputs, post-pay review, overpayment recovery, or FWA/SIU workflowsAdvanced Excel, dashboarding, and data visualization skillsBenefitsAnnual Incentive Bonus*401(k) with employer matchPaid Time Off (PTO)Competitive health benefits and wellness programsMedical, dental, and vision coverage along with numerous health and wellness programsParental leave and support plus adoption and surrogacy assistanceCareer development programs and tuition reimbursement for continued education401k match including an annual company contributionCompany OverviewIt's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. It was founded in 1933, and is headquartered in Durham, North Carolina, USA, with a workforce of 5001-10000 employees. Its website is https://www.bluecrossnc.com/.