Director, Payment Integrity

Medica • Minnetonka, MN

113d • $111,200 - $190,600

About The Position

The Director of Payment Integrity will lead efforts in claims cost management identification and implementation of cross functional opportunities resulting in operational efficiency, claim payment accuracy and adherence to industry standard practices. Initiatives will be delivered via internal operational processes and performance management as well with the use of external vendors. This leadership position is accountable for cost containment strategy development and execution via payment integrity business processes (e.g., reimbursement policy development/maintenance, high dollar audits, health care error/waste/abuse detection and intervention, and implementation and management of claims editing and pricing software) to achieve $50MM+ in annual medical expense savings; plays a lead role on the company's Affordability Committee in relation to Policy & Configuration; recruits and manages insourced and outsourced talent. The most critical skills and experience required for this role involve: a) designing and implementing a strategic capability development roadmap (new process, technology, people capabilities) for the departments and functions discussed above, while b) simultaneously optimizing near-term operational performance (within fixed process, technology, people constraints) to ensure key performance indicators (KPIs) and appropriate regulatory/compliance standards are met. Performs other duties assigned.

Requirements

• Bachelor's degree or equivalent experience.
• 8+ years of experience in the Healthcare setting.
• 5+ years of leadership in Operations roles.
• At least 10 years' experience in medical claims payment cost containment or payment integrity.

Nice To Haves

• Clinical and/or healthcare claims operational experience strongly preferred.
• Knowledge of claims payment standards and regulations.
• Strong communication skills.
• Strong experience creating, presenting and reporting outcomes to executive leadership.
• Experience with IT capability development to drive and enable operational and vendor solutions.
• Demonstrated ability to develop and implement new strategies.
• Understanding of how to set, measure and adjust organization metrics/key performance indicators.
• Experience identifying, evaluating, implementing, and overseeing vendor solutions.
• Demonstrated experience in developing multi-year Health Plan Operations' strategies.
• Large project and/or program management experience.
• Ability to influence individuals at all levels of leadership.
• Ability to provide work direction and coaching to individuals not under direct authority.

Responsibilities

• Develops Payment Integrity future functional strategies and capability roadmaps.
• Identifies how these functions must change/evolve to support Medica 2022-2024 Strategic Plan.
• Directs and incorporates industry benchmarks in building strategies/roadmaps.
• Maintains three-year future state services strategy.
• Establishes priorities for multi-year work/related individual projects.
• Leads and/or supports related (Six Sigma/LEAN) process engineering efforts.
• Employs quantitative analysis methodology to perform data, cost and benefit, and/or process measurement analysis.
• Develops and manages change management discipline and associated processes.
• Directs and oversees payment integrity business process, staff and annual savings targets.
• Accountable for the speed/TAT, accuracy, and work quality of workflows.
• Oversees development of staffing plans.
• Develops new/revised metrics/KPIs on an annual basis.
• Monitors metrics performance and develops formal service recovery plans.
• Selects and manages key vendor partners for payment integrity services.
• Ensures functional interests are reflected in IT Demand management process.

Benefits

• Competitive medical, dental, vision.
• PTO.
• Holidays.
• Paid volunteer time off.
• 401K contributions.
• Caregiver services.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Industry: Professional, Scientific, and Technical Services
• Education Level: Bachelor's degree