Mgr, Payment Integrity

Corewell Health • Grand Rapids, MI

7d • Onsite

About The Position

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.

Requirements

• 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
• An in-depth understanding of provider payment methodologies and concepts (DRGs, capitation, RBRVS payments, APC, percent of charges, etc.)
• Well versed with State and Federal regulations related to healthcare billing and coding
• Experience with health care claims
• Direct experience in hospital or physician billing, or equivalent experience with a managed care payer

Nice To Haves

• Experience working with government programs including Medicare, Medicaid and FEHB
• CRT-Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire
• CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire
• CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire
• CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire
• CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire
• CRT-Professional Coder, Certified - Payer (CPC-P) Upon Hire
• CRT-Professional Coder, Certified - Hospital Outpatient (CPC-H) Upon Hire

Responsibilities

• 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.

Benefits

• Comprehensive benefits package to meet your financial, health, and work/life balance goals.
• 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

What This Job Offers

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