Job Description
Sr. Strategic Advisor, Medicare Payment and Reimbursement
Blue Cross NC Medicare is a high-performing Medicare Services Organization (MSO) supporting North Carolina Medicare Advantage members operating under full-risk value-based care arrangements. As a fully delegated MSO, BCBSNC assumes accountability for claims adjudication, provider payment, and regulatory CMS compliance on behalf of partner health plans and providers.
The Sr. Strategic Advisor, Medicare Payment & Reimbursement Policy Advisor serves as a senior individual contributor and subject matter expert supporting the interpretation, application, and operational alignment of Medicare payment and reimbursement policies. This role serves as a liaison between Segment, Clinical Policy, Product, Network, and Operations including claim processing, capitation and value-based arrangements, and administration of product design.
The position operates collaboratively across Claims, Provider Configuration, Finance, Compliance, IT, and Health Plan partners, contributing to consistency, audit preparedness, and payment accuracy, while working within established governance and operational structures.
Role Focus
From a CMS and delegation perspective, this role functions as:
A key advisor supporting translation of regulation into payment operations
A contributor to policy validation and audit readiness efforts
A subject matter resource helping prevent inconsistencies in reimbursement application
The Sr. Strategic Advisor does not own compliance, claims operations, or enterprise governance, but plays a critical role in supporting correctness, defensibility, and consistency of Medicare payment outcomes through expert analysis and advisory partnership.
Core Areas of Accountability
Medicare Advantage payment and reimbursement policy interpretation.
Collaboration with compliance and operations in the evaluation and application of CMS guidance via HPMS Memos and HLN Bulletins
A Clinical or payment policy approval, validation support, and risk identification.
Translation of policy requirements into operational guidance
Medicare requirements for product, clinical policy or payment policy.
Regulatory and delegation compliance support.
Strategic advisory input on reimbursement risk and implication
Serve as a senior subject matter expert on Medicare Advantage payment, reimbursement, and claims-related CMS policy.
Interpret and evaluate CMS guidance, health plan reimbursement direction, delegation requirements, and contractual payment terms.
Assess the operational and compliance implications of new or updated CMS guidance, health plan bulletins, and MLN updates.
Provide advisory input to leadership on reimbursement-related risks, ambiguities, and potential financial impacts.
2. Policy Review & Payment Integrity Support
Support periodic reviews of Medicare payment and reimbursement application across claims adjudication and provider payment processes.
Assist in validating that claims logic and provider payment processes align with CMS and health plan requirements.
Identify and escalate potential policy misinterpretation, inconsistent application, or configuration gaps that could lead to payment variance or compliance risk.
Partner with Finance, Actuarial, and Compliance teams to support payment integrity reviews, reconciliations, and remediation activities.
3. Translation of Policy into Operational Guidance
Collaborate with Claims Operations and Provider Configuration teams to translate Medicare reimbursement policy into clear operational guidance, including system, configuration or process requirements:
Claims adjudication considerations
Provider configuration standards
Fee schedules and payment methodologies
Develop and maintain documentation connecting regulatory policy language to operational execution to reduce interpretation risk.
4. Configuration & Adjudication Advisory Support
Participate as a subject matter advisor in configuration and adjudication discussions to support reimbursement accuracy and policy alignment.
Review proposed configuration or process changes driven by CMS guidance, health plan updates, or contractual changes for consistency with policy intent.
Support root-cause analysis of claims issues where reimbursement outcomes signal potential policy or configuration concerns.
5. Regulatory, Delegation & Audit Readiness Support
Partner with Compliance and operational teams in preparation for CMS audits, health plan delegation audits, and internal reviews.
Support documentation and evidence development related to Medicare reimbursement policy application.
Assist with reimbursement-related corrective action planning by providing policy interpretation and operational alignment guidance.
6. Strategic Advisory & Cross-Functional Collaboration
Provide strategic input to Medicare leadership on reimbursement-related risks, trends, and regulatory considerations.
Educate operational partners on Medicare reimbursement policy impacts in a practical, execution-focused manner.
Serve as a trusted advisor during periods of regulatory change, system updates, or audit activity.
Qualifications & Experience
Required
Bachelor’s degree in Healthcare Administration, Business, Finance, or related field
5 years of relevant experience
Medicare Advantage experience with exposure to reimbursement, claims payment, or payment policy
Strong working knowledge of CMS Medicare Advantage payment regulations
Experience operating in a matrixed or shared-services environment
Understanding of claims adjudication logic, provider payment methodologies, and claims platforms (e.g., FACETS)
Preferred
Master’s degree (MBA, MHA, or related)
Experience supporting CMS audits, payment integrity initiatives, or regulatory reviews
Familiarity with configuration tools and reimbursement analytics
Exposure to multiple MA products (MA, D-SNP, PDP)
Core Competencies
Medicare reimbursement policy expertise (CMS)
Strong analytical and problem-solving skills
Practical judgment with a consultative advisory approach
Ability to translate regulatory requirements into clear operational guidance
Effective communication across technical and non-technical teams
Steady, credible presence in high-impact or au
Salary Range
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*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.
*Based on annual corporate goal achievement and individual performance.
$89,174.00 - $142,679.00
Skills
Healthcare Consulting, Healthcare Financial Management, Healthcare Industry, Healthcare Innovation, Healthcare Management, Healthcare Reimbursement, Healthcare Strategic Planning, Health Outcomes, Medical Reimbursement, Performance Metrics, Physician Reimbursement, Project Management, Provider Reimbursement, Reimbursement, Reporting and Analysis
JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: HR.Staffing@BCBSNC.com.