Mgr, Payment Integrity

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. 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 Healthcare, Nursing, or Business 5 years of relevant experience Healthcare claim auditing or equivalent combination of; auditing, medical coding, healthcare revenue cycle, or regulatory (i.e., CMS & Medicaid) experience Required 5 years of relevant experience An in-depth understanding of provider payment methodologies and concepts (DRGs, capitation, RBRVS payments, APC, percent of charges, etc.) Required 5 years of relevant experience Well versed with State and Federal regulations related to healthcare billing and coding Required Experience with health care claims Required Direct experience in hospital or physician billing, or equivalent experience with a managed care payer Preferred Experience working with government programs including Medicare, Medicaid and FEHB Preferred CRT-Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire preferred Or CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire preferred Or CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire preferred Or CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire preferred Or CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire preferred Or CRT-Professional Coder, Certified - Payer (CPC-P) - UNKNOWN Unknown Upon Hire preferred Or CRT-Professional Coder, Certified - Hospital Outpatient (CPC-H) - UNKNOWN Unknown Upon Hire preferred 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 ¹ [None = No; Seldom = Yes]: Seldom How Corewell Health cares for you Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here . On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - Priority Health - 1239 E Beltline Ave NE - Grand Rapids Department Name Payment Integrity Value and Analysis - PH Managed Benefits Employment Type Full time Shift Day (United States of America) Weekly Scheduled Hours 40 Hours of Work 8:00 - 5:00 Days Worked Monday - Friday Weekend Frequency N/A CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplac