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

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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 workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.