Manager of Payment Integrity

The Manager of Payment Integrity is responsible for the oversight day-to-day operations of the Payment Integrity Auditors, Quality Control (QC) Claims Auditors and other Payment Integrity staff. The Manager will oversee payment integrity coding and clinical validation operations ensuring compliance with regulatory and internal standards and leading strategies to minimize payment errors and inefficiencies. This role involves analyzing claims, reviewing payment processes and working collaboratively with internal teams and external vendors. Responsible for oversight of workforce management, data analysis, internal and external policy development and management, internal training and administrative support.

Duties and Responsibilities:

Responsibilities include, but are not limited to:

• Responsible for managing the day-to-day operations of the Payment Integrity team
• Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
• Design and implement standards and metric tools and reporting for the QC claim audit team
• Oversight of department reporting to ensure necessary reports and dashboards are regularly and accurately produced to evaluate the claims administration practices related to QC
• Report on key performance indicators related to payment integrity programs and operations effectiveness
• Serve as the subject matter expert and lead on functional deliverables ensuring optimal efficiency in area of responsibility
• Work together with internal and external collaborators, including healthcare providers, vendors, and regulatory bodies to ensure payment integrity, resolve complex issues, and eliminate team roadblocks
• Ensure compliance with industry regulations, internal policies and external audits
• Ensure that provider claims are paid correctly by the responsible party, for eligible members, according to contractual terms, not in error or duplicate
• Write and administer timely comprehensive performance appraisals of assigned staff.
• Use data-driven insights to identify trends, optimize processes and anticipate challenges
• Responsible for staying current on industry trends and standard methodologies related to payment integrity

• Ensure compliance of EOHHS and CMS as required by the contract and other State / Federal regulations.
• Initiate and recommend focused audits, system and process improvements to assist in the identification of opportunities for enhanced departmental performance.
• Work with the Director to recommend changes, develop or modify policies and procedures to enhance Payment Integrity's performance.
• Report to the Director findings, root causes and present to various business areas within Neighborhood when appropriate.
• Work with the Director to develop and monitor the annual Payment Integrity budget

• Performs other related duties and special projects as required or assigned.
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications:

Required:

• Bachelor's degree in business or health-related discipline, or equivalent work experience and background to equate to the degree.
• Four (4) + years of health care experience, preferably in a managed care setting.
• Three (3) + years of Medicaid, Medicare and/or Commercial insurance experience
• Strong leadership skills and prior management experience
  
  
  
  • Ability to lead others to achieve desired results, including (but not limited to):
  • Ability to assess individual performance and communicate assessments effectively
  • Ability to identify and effectively and efficiently resolve employee performance issues
  • Ability to establish goals and assist others to achieve goals and meet expectations
  • Ability to lead others to improve work processes
  
  
  
  
• Possess and understanding of healthcare, claims adjudication, revenue cycle management and payment integrity
• General understanding of Coordination of Benefits and the order of benefits rules
• Knowledge and understanding of HIPAA standards, CMS guidelines, EDI, UB04 and CMS 1500 data elements as well as NUBC requirements
• Proficiency with PC applications including Microsoft Office (Word, Excel & Outlook)
• Demonstrated ability to train and mentor assigned employees in all technical aspects of their job responsibilities
• Demonstrated ability to deal effectively with company management, peers and co-workers
• Demonstration of sound judgment and strong decision-making skills
• Ability to work independently and collaboratively will all business areas throughout the organization.
• Strong process orientation and analytical capabilities, with demonstrated ability to implement change.
• Experience in medical records review, claims processing or utilization/case management in clinical practice or managed care organization
• Fundamental knowledge of Medicare/Medicaid Guidelines
• Experience with provider payment methodologies
• Excellent organizational and troubleshooting skills.
• Experience in managing external vendors.
• Excellent written, verbal and interpersonal skills.
• Team oriented

Preferred:

• Coding Certification, American Academy of Professional Coder's (AAPC) COC and/or CIC
• Knowledge of COGNOS reporting environment
• Project Management experience

Salary Grade: H

Neighborhood Health Plan of Rhode Island 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 veteran status.