Payment Integrity Coding Manager

CareOregon•WFH (Oregon), OR

1d•Remote

About The Position

The Payment Integrity Coding Manager is responsible for developing, implementing, and continuously improving enterprise-wide payment integrity and claims programs and strategies to ensure that CareOregon’s claims editing, coding compliance, provider education, audit and recovery, and quality assurance, align with organizational goals and compliance with American Medical Association (AMA), Centers for Medicare & Medicaid Services (CMS), and state regulatory requirements. The position requires effective alignment and integration with multiple internal and external teams and stakeholders including, but not limited to, coordination between vendors, legal, audit, compliance, finance, data analytics and network operational functions. The Manager partners closely with internal and external stakeholders—including vendors, Legal, Audit, Compliance, Finance, Data Analytics, Network Operations, Provider Relations, and Clinical Operations—to drive accurate payments, mitigate risk, and optimize recoveries. The role also oversees user acceptance testing (UAT) for system changes impacting claims and coding and develops business cases to scale payment integrity initiatives.

Requirements

Minimum 5 years’ management experience in health plan claims operations, audit, and/or payment integrity.
Minimum 5 years’ experience as a certified coder and/or Certified Coding auditor with active certification AHIMA or AAPC (e.g., CPC, CCS, CCA, CMC or equivalent).
Strong understanding of state and federal regulations that impact operations in order to properly respond
Knowledge of how to confidently navigate through complex and challenging business issues
Working knowledge of different claims coding requirements and payment methodologies (e.g., PPS, Medicare fee schedules, etc.)
Knowledge of medical terminology
Knowledge and skill in claims system management, editing software, and coding
Strong detail-orientation skills
Strong project management skills
Adept at prioritizing work
Ability to develop payment processes and solutions for low income, Medicaid, and Medicare populations
Comprehensive program development, management and evaluation skills
Statistical, analytical, problem-solving and organizational skills
Excellent spoken, written and presentation communication skills
Ability to use computer programs commonly used for health plan operations
Ability to lead and influence change and results
Skill in negotiation and ability to build consensus
Skill in leading people, including the ability to coach and mentor staff
Excellent interpersonal skills
Ability to maintain professional relationships with internal and external staff and departments
Ability to present a positive and professional image as a leader and representative of CareOregon
Ability to work well under pressure in a complex and rapidly changing environment
Ability to support and comply with organizational policies, procedures and guidelines
Ability to work effectively with diverse individuals and groups
Ability to learn, focus, understand, and evaluate information and determine appropriate actions
Ability to accept direction and feedback, as well as tolerate and manage stress
Ability to see, read, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/day

Nice To Haves

Performing statistical claims analysis in a managed care or health care setting.
Experience in and/or understanding of payment integrity programs and vendors.
Experience with SQL Server Reporting, or using business intelligence tools (e.g., Tableau) and data framework.

Responsibilities

Oversee monitoring, analysis, and reporting of claims activity (e.g., trends, outliers, high-cost claims, line-of-business segmentation).
Manage development and maintenance of tracking mechanisms, dashboards, and documentation related to audits, findings, and overpayment recoveries.
Ensure accurate invoicing and reconciliation for programs and vendors; oversee processing of recoupments and refunds.
Identify root causes of overpayments, track trends, and drive corrective actions with accountable owners.
Define and execute the enterprise payment integrity and coding audit strategy; align program goals with CareOregon’s mission, vision, values, and strategic plan.
Build business cases and ROI models to expand initiatives, resources, and technology enabling sustainable savings and improved accuracy.
Establish governance, KPIs, and reporting cadence for program performance, savings, recoveries, and risk mitigation.
Lead a portfolio of coding audits (prospective and retrospective), ensuring accurate capture of diagnosis and procedure codes in claims and chart review data.
Serve as subject matter expert for ICD-10-CM/PCS, CPT/HCPCS, and associated coding conventions; actively maintain and enforce AMA/CMS guidelines.
Lead Risk Adjustment Data Validation (RADV) and related diagnosis code audits (for Finance/Risk Adjustment as applicable).
Develop and deliver training and education for providers and internal stakeholders (e.g., recorded modules, reference guides, job aids).
Create and maintain centralized policy, process, compliance documentation, and SOPs related to coding and risk adjustment.
Manage a team of quality auditors responsible for testing the accuracy of transactional processing.
Track, trend and report on quality audit results on a weekly, monthly, quarterly and year-to-date basis.
Develop or expand performance metrics to assess the quality of our payments and their improvement over time.
Identify and recommend changes/enhancements to processes, processing guides and/or internal tools to achieve improved quality outcomes.
Develop, manage and schedule Operations user acceptance testing, scripting, playbooks and job aides.
Work with CareOregon departments to develop and oversee standard operating procedures to ensure that consistent business rules are applied in claim adjudication.
Review claims, hospital bills, and physician notes and data to devise and refine procedures for identifying billing errors and resolving problematic provider billing practices.
Work with the Provider Relations team and the Audit and Compliance team to develop ongoing processes for auditing provider bills, recording errors and tracking collections.
Work closely with data analysts, clinical operations, technical, legal and operational teams to create sustainable and scalable cost savings solutions.
Use data analytics to find new opportunities to expand the scope of payments reviewed.
Perform variance analysis, assist with medical claims reconciliation and payment process development/improvement.
Align with fraud waste and abuse reduction initiatives and lead resultant initiatives and projects.
Develop and maintain department’s policies, procedures and workflows.
Develop training documents and conduct process trainings on a regular basis.
Identify opportunities for improvement and recommend solutions.
Manage team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.
Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
Train, supervise, motivate, and coach employees; provide support toward employee development.
Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.
Ensure team adheres to department and organizational standards, policies, and procedures.
Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).
Perform supervisory tasks in collaboration with Human Resources as needed.
Perform work in alignment with the organization’s mission, vision and values.
Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
Strive to meet annual business goals in support of the organization’s strategic goals.
Adhere to the organization’s policies, procedures and other relevant compliance needs.
Perform other duties as needed.

Benefits

Competitive pay
Bonus opportunity
Medical insurance
Dental insurance
Vision insurance
Life insurance
AD&D insurance
Disability insurance
Health savings account
Flexible spending account(s)
Lifestyle spending account
Employee assistance program
Wellness program
Discounts
Multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)
Strong retirement plan with employer contributions
PTO
Paid State Sick Time
Paid holidays
Volunteer time
Jury duty
Bereavement leave
401(k) contributions