Manager Payment Integrity

Highmark Health • PA, Working at Home - Pennsylvania, PA

17h • $86,400 - $138,600 • Onsite

About The Position

This job is responsible for the overall pre-payment high dollar claims review process for Highmark including the review of itemized bills for saving on outlier claims. This requires interaction and regular coordination with Utilization Management, Facility Revenue Cycle Teams, Provider Relations and Sales. Every claim paying over a certain amount is reviewed by this team utilizing multiple lenses including processor quality and the assignment of errors to individual claims processors as well as claims payment accuracy. The incumbent also represents Highmark at the Association level with regards to the High Dollar Claims process across the Blues, providing feedback and influencing change when necessary. Additionally, the incumbent is responsible for identifying system issues/defects primarily from a claim processing perspective and generating recoveries via auditing and claims adjustments. These savings are apart of C2V under the Claims Leakage team. The incumbent works with various internal parties, as well as Highmark Health Solutions to bring system defects to resolution while mitigating leakage developing workarounds until a solution can be implemented. The team interacts regularly with other areas within Payment Integrity to provide consulting on complex claims processes as well as provides adjustment support to the other areas including the vendor team and the clinical teams.

Requirements

• Bachelor's Degree in Business Administration/Management or 6 years of related experience in lieu of a Bachelor's Degree
• 5 years in Operational Claims
• 3 years in a management or leadership role
• Analytical Skills
• Change Control
• Claims/Benefit Systems
• Financial Forecasting/Modeling
• Microsoft Excel
• Health Care Operations

Nice To Haves

• 3 years in Process Improvement
• 3 years in Medicare
• 1 years in Project Management
• Project Management Professional (PMP)
• Certified Fraud Investigator (CFE)
• Certified Professional Coder (CPC)

Responsibilities

• Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
• Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
• Plan and assign personnel, provide project oversight and ensure work accuracy on various Payment Integrity related claims audits.
• Provide instructions and direction to other staff regarding technical solutions to meet business issues, as well as, anticipate impact and propose solutions.
• Performs analysis and documents audit requirements as well as assists in the design of system enhancements via the Change Request process to boost claims payment accuracy.
• Communicate issues and resolutions both within the Operational areas and outside including regular coordination with Financial Investigations and Provider Review (FIPR), Provider Relations, and Sales.
• Ensure overall savings targets are achieved. This includes realignment of priorities to ensure resources are properly aligned to effectively achieve annual savings targets.
• Exercise, on a daily basis, discretion in the supervision of business analysts, development of processes and procedures to improve claims accuracy, influence systematic changes, provide strategic guidance and implement or recommend workable solutions.
• Represents Highmark as the key contact for the Association mandated High Dollar Claims process which includes recommending process changes, providing feedback on current processes, influencing change and interacting with other Blue Plans on a regular basis.
• Other duties as assigned or requested.

Benefits

• Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.
• The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

What This Job Offers

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