Job Summary
Responsible for management of all aspects of the Payment Integrity Program with specific expertise in healthcare payment and reimbursement. The Payment Integrity Manager is responsible for managing staff and associated activities to ensure that saving opportunities are initiated, executed, and reported. These efforts will support the organization's cost containment efforts specific to medical claims payment and drive payment integrity performance. This position is responsible for coordinating with organizational Executive leadership in setting the priorities, goals and objectives of the Payment Integrity program. Organization strategy will be supported by coordinating with Medical Policy and Provider Relations teams to effectively plan and execute program tactics.
Manage the vendors that are hired to perform Universal program review and audit functions for Priority Health. Oversee all activities associated with delivering an audit service from Statement of Work (SOW) creation to delivery of contract terms. Identify risk associated with incorrect payment decisions, audit outcome impacts, provider impacts, compliance or other health plan obligation that might involve actions by a vendor or the vendor's program operation. Assure oversight of efficient and correct vendor data exchange through other employees who execute them.
Essential Functions
Develops an annual risk assessment and audit plan to support the organization's Payment Integrity Strategy.
Develop/sustain and engagement model between the Claims integrity function and other business units within the organization.
Manages and coordinates substantive audits of medical claims, done internally and externally, for appropriateness of billing and payment, including investigation of inappropriate bundling/unbundling of services, erroneous and duplicate billings, data-entry omissions and errors, and inappropriate payments. Accurately summarizes and report findings to coordinate Provider communication and recovery of funds.
Collaborates with Medical, Pharmacy, and Provider teams to determine the best course of action to align policies supporting cost containment activities.
Establishes process for case assignment to review and respond to Provider appeals.
Knowledge and understanding of plan products, payment methodologies, medical and payment policies.
Reviews and provides feedback on provider agreements, member materials, and other internal documents impacted by the Payment Integrity program.
Interviews, hires and manages staff to best prioritize and coordinate work efforts supporting efficient and effective cost containment activities specifically related to medical claims payments.
Qualifications
Required
Bachelor's Degree or equivalent in Healthcare, Nursing, or Business
5 years of relevant experience working with Healthcare claim auditing or equivalent combination of; auditing, medical coding, healthcare revenue cycle, or regulatory (i.e., CMS & Medicaid) experience
5 years of in-depth understanding of provider payment methodologies and concepts (DRGs, capitation, RBRVS payments, APC, percent of charges, etc.)
5 years of relevant experience working with State and Federal regulations related to healthcare billing and coding
Experience with health care claims
Preferred
Direct experience in hospital or physician billing, or equivalent experience with a managed care payer
Experience working with government programs including Medicare, Medicaid and FEHB
CRT - Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire or
CRT - Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire or
CRT - Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire or
CRT - Coding Specialist, Certified - Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon or
CRT - Professional Coder - AAPC American Academy of Professional Coders Upon Hire or
CRT - Professional Coder, Certified - Payer (CPC-P) Upon Hire or
CRT - Professional Coder, Certified - Hospital Outpatient (CPC-H) Upon Hire
Physical Demands
Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
Waist to Waist > 5 lbs: Seldom up to 10 lbs
Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
Waist to Overhead > 5 lbs: Seldom up to 10 lbs
Bilateral Carry > 5 lbs: Seldom up to 10 lbs
Unilateral Carry > 5 lbs: Seldom up to 10 lbs
Pushing Force > 5 lbs: Seldom up to 10 lbs
Pulling Force > 5 lbs: Seldom up to 10 lbs
Sitting: Frequently
Standing: Occasionally
Walking: Occasionally
Forward Bend - Standing: Seldom
Forward Bend - Sitting: Occasionally
Trunk Rotation - Standing: Seldom
Trunk Rotation - Sitting: Occasionally
Reach - Above Shoulder: Seldom
Reach - at Shoulder or Below: Seldom
Handling: Occasionally
Forceful Grip > 5 lbs: Seldom
Forceful Pinch > 2 lbs: Seldom
Visual Acuity
[None = No; Seldom = Yes]: Seldom
Primary LocationSITE - Priority Health - 1239 E Beltline - Grand Rapids
Department NamePH - Payment Integrity Leadership
Employment TypeFull time
ShiftDay (United States of America)
Weekly Scheduled Hours40
Hours of Work8:00 a.m. to 5:00 p.m.
Days WorkedMonday to Friday
Weekend FrequencyN/A
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Corewell Health is committed to providing a safe environment for our team members,... For full info follow application link.
Beaumont Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity, sexual orientation, age, status as a protected veteran, or status as a qualified individual with a disability.
