Senior Manager, Payment Integrity

Medica•,

3d•$88,800 - $152,300•Remote

About The Position

The Senior Manager, Payment Integrity is responsible for the teams who focus on Prepayment and Post Payment reviews related to waste/error and primary and secondary editing vendors. The primary focus of these team members and vendors are to ensure appropriate provider claim payment. The position will include visibility to senior leadership through reporting of results and trending of findings and savings month over month. This position will be responsible for reverse engineering vendor savings, identifying medical cost leakage, share insight and absorb information that may lead to future findings and/or expansion opportunities. The duties of this position will have oversight and responsibility for communicating team results and working collaboratively to drive improvements through trending of pre-payment solutions, recoveries, the accuracy of claims payment, volume of claims adjustments, impact to provider service, degree of financial liability, and impact to provider billing pattern changes. In addition, this position will be responsible for new payment integrity related implementations are successful. Performs other duties as assigned.

Requirements

Bachelor's degree or equivalent experience in related field
7+ years of work experience beyond degree including 5+ years of people leadership experience and 4+ years of reimbursement policy experience

Responsibilities

Development, monitoring and reporting of goals and metrics for waste and error reviews and effectiveness.
Achievement of department production goals
General management duties (coaching, team, staff and 1:1 meetings, issue identification, escalation and resolution, performance measurement
Department recruitment, selection, retention and performance improvement in coordination with department director
Perform annual performance reviews
Develop and maintain staff morale and promote teamwork.
Provide recognition to staff through the reward and recognition programs
Coach, encourage and facilitate individual growth and development through specific, timely and consistent feedback
Provide technical support to staff by assisting them timely. Guide them to other appropriate resources, if needed. Ensure they receive the training needed to help them be successful in their daily roles as well as provide them opportunities for growth
Collaborate with the team to create and maintain department policies, procedures and swim lanes
Assure processes are established between Medica, post-pay compliance vendors, the claims processing vendors, and editing system vendors.
Continue to build and expand into new areas and vendors for payment integrity identification and resolution.
Oversee and ensure successful implementations of any new payment integrity related processes and/or vendors.
Maintain and enhance, as needed, executive reporting package
Comprehend Medica’s contracting strategy and how it relates to our provider reimbursement and system capabilities
Report overpayments or suspected fraudulent and/or abusive behavior to our Special Investigations Unit (SIU)
Monitor, manage and report financial impact to management
Maintain reporting structure by ensuring consistency to both internal and external customers
Improve processes through automation and/or efficiencies in process
Review and analyze team findings/savings on a monthly, quarterly and annual basis to identify trends, areas for focus and improvement
Assure processes are auditable (able to be reperformed with a paper/electronic trail)
Develop a forecast of potential and error savings goals for analyzing our claims data.
Oversee the day-to-day processes used by analysts to perform monthly savings and recovery efforts.
Recover overpayments identified through retrospective data analytics.
Uncover root cause of errors, influence stakeholders, sponsor process improvement, and continuously enhance claims editing solutions
Develop and maintain good working relationship with Medica’s claim processing teams and vendors to drive ongoing payment integrity management to enhance claim processing accuracy and adjustment reduction.
Maintain up-to-date knowledge of corporate policies, regulatory codes, legislative directive, and other guidelines
Set priorities for staff dedicated to following up on payment integrity leads from vendors and internal referrals
Be available to internal and external customers as a subject matter expert in the area of waste and errors; and the general processes performed by payment analytics and reimbursement policy.
Effectively manage and/or participate in projects as assigned by director
Educate and advise customers about the processes, content and trends
Assure integration and collaboration with other Medica stakeholders including pharmacy ops, payment intent/cost containment, network management, SIU, claims operations, clinical services, operations audit and internal audit