Director - Payment Integrity

Point32Health • Canton, MA

1d

About The Position

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health. Job Summary Reporting to the Vice President of Payment Integrity, the Director, Payment Integrity will lead the development and execution of strategies to optimize payment accuracy and expand the organization's audit capabilities. The Director will be responsible for daily oversight of key functions including Payment Policy, Edit configuration and maintenance, management of multiple internal teams and external vendor audit functions, oversight of vendor arrangements including contract amendments and SLAs, management of Base Fee Schedules. The Sr. Director is also responsible for developing Payment Integrity Strategy, implementation and management of all functions.

Requirements

• Bachelor's degree in Healthcare Administration, Business Administration, or a related field
• 5 years leadership/management experience required in related Payment Integrity/Audit functions.
• Experience managing external audit vendors and/or internal audit teams
• Operational experience with pricing software, edit vendors and software and Policy development
• Exhibit leadership capabilities and demonstrated ability to effectively work with all levels and cross-functionally within the company.
• Experience managing in a fast paced, high volume, transaction-driven environment necessary.
• General knowledge of health insurance products.
• Health insurance claim management experience preferred for a period of at least three-five (3-5) years.
• Knowledge of Medicare and Medicaid Regulations is preferred.
• Strong subject matter expertise and knowledge of all relevant laws, contractual requirements, industry standards and best practices required.
• Strong understanding of healthcare delivery systems, provider reimbursement methodologies, and regulatory requirements.
• Excellent communication, negotiation, and relationship and team building skills, with the ability to collaborate effectively with internal and external stakeholders.
• Strategic thinking and analytical skills, with the ability to develop and execute complex provider network strategies.
• Knowledge of healthcare IT systems and tools, including provider databases, claim processing systems, and network analytics platforms.
• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Nice To Haves

• Master's degree

Responsibilities

• Oversight of day-to-day Payment Integrity $550+ million portfolio and functions.
• Meet or exceed annual savings targets established by leadership through Total Cost of Care efforts which are typically 8-10% incremental goals year over year.
• Responsible to develop new programs and continually improve existing programs while evaluating the most efficient and cost-effective way to manage recovery work and achieve goals.
• Strategic Planning: Continually review Payment Integrity vendor relationships, internal staffing, infrastructure and tools and develop short and long term plans that link to a comprehensive approach to Policy, edit and audit work necessary to achieve established corporate goals, enhance operational efficiencies and ensure that accuracy of claim payment.
• Performance Monitoring and Analysis: Develop and implement metrics and key performance indicators (KPIs) to monitor Payment Integrity performance, including vendor management of contractual SLAs and/or expected adherence to workflows, QC and submission guidelines, decisions around vendor pass positions, ability to achieve expected savings targets and management of accurate reporting. The Sr. Director will analyze data and trends to identify opportunities for process improvements and new savings opportunities and ensure that we remain competitive relative to other payors in our service area.
• Compliance and Regulatory Compliance: Ensure compliance with all relevant regulatory requirements, accreditation standards, and contractual obligations related to edit and audit functions. Stay informed and react quickly to changes in healthcare regulations and industry trends that may impact provider contracting and reimbursement practices.
• Strategic Partnerships: Collaborate with internal department leadership as needed to understand and react appropriately to provider concerns to assist with the corporate provider experience initiatives
• Other projects and duties as assigned.

Benefits

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

What This Job Offers

• Job Type: Full-time
• Career Level: Director