Senior Manager, Program Integrity (CPC, RHIT or RHIA required)

CareSource•Dayton, OH

About The Position

Job Summary: The Senior Manager, Program Integrity is responsible to provide leadership and direction to ensure the goals and strategies of the department are successfully achieved. Essential Functions: Implement optimization opportunities for prepay and post pay medical record auditing procedures and processes improvement auditing timeliness and quality outcomes Oversee and ensure that supporting business and regulatory processes and documentation exists and kept current Track and communicate production issues and escalations to ensure proper follow-up and coordination Maintain project plans for all projects in which configuration is involved and ensure proper completion of those plans and escalation where timeframes will be changed Lead new product and new vendor implementations to ensure timeliness and quality of new implementations Develop and implement ticket controls and ensure that proper communication and approvals are in place prior to system implementation Participate in strategic planning and implement action plans Oversight and management of team of medical record coding auditors Analyze and make a determination of appropriate reimbursements and/or modifications of Coding review guidelines in partnership with medical directors and clinical staff. Contribute to new business readiness through comprehensive coding audit requirements Review bulletins, newsletters, periodicals and attend workshops to stay abreast of current issues and trends, changes in laws and regulations governing medical record coding and documentation Develop and update procedures to maintain standards for correct medical record auditing or coding to minimize the risk of fraud, waste, abuse and error Provide expertise in regard to analytic software and coding which requires knowledge of coding/reimbursement/policy Provide oversight of documenting code editing solutions, testing and promotion of changes following established departmental change management processes Oversee research of analysis of data in relation to code edits and to draw conclusions to resolve issues as it relates to edits, including participation on provider calls Consult in predictive analytic modeling refinement to drive lower false positives Monitor and manage applicable departmental expenses based on current year’s budget Generate and maintain reportable QAI savings for the department and report combined annual savings based on vendor and line of business Provide oversight and expertise of reimbursement methodology pertaining to Ambulatory Procedural Coding (APC), Diagnosis Related Groupers (DRG) and Outpatient Prospective Payment System (OPPS) as well as professional claim reimbursement Responsible for hiring, coaching, development and performance management of staff Perform any other job duties as requested

Requirements

Bachelor’s degree or equivalent years of relevant work experience is required
Minimum of five (5) years of experience in medical policy is required
Minimum of five (5) years of management experience is required
Health plan experience is required
Facets and clinical editing system or equivalent system experience is required
Advanced computer skills and abilities in Facets
Medical terminology knowledge
Proficient in Microsoft Suite to include, Word, Excel, and Access
High level of programming and systems development knowledge
Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of business partners
Demonstrated ability to successfully define a portfolio of initiatives including business requirements gathering, definition/prioritization, project scope definition, project staffing requirements, application configuration, testing approach, training, documentation, reporting strategy, and change management process
Knowledge of regulatory reporting and compliance requirements
Excellent written and verbal communication skills
Effective listening and critical thinking skills
Strong interpersonal skills and high level of professionalism
Leadership/management skills
Effective problem-solving skills with attention to detail
Ability to work independently and within a team
Ability to develop, prioritize and accomplish goals
Knowledge of medical claims payment workflow and processing applications
Strong working knowledge of Medical Record auditing and oversight of large teams
Certified Medical Coder (CPC, RHIT or RHIA) is required

Nice To Haves

Healthcare, technology and EDI issues experience is preferred
Active, unrestricted Registered Nurse (RN) license is preferred

Responsibilities

Implement optimization opportunities for prepay and post pay medical record auditing procedures and processes improvement auditing timeliness and quality outcomes
Oversee and ensure that supporting business and regulatory processes and documentation exists and kept current
Track and communicate production issues and escalations to ensure proper follow-up and coordination
Maintain project plans for all projects in which configuration is involved and ensure proper completion of those plans and escalation where timeframes will be changed
Lead new product and new vendor implementations to ensure timeliness and quality of new implementations
Develop and implement ticket controls and ensure that proper communication and approvals are in place prior to system implementation
Participate in strategic planning and implement action plans
Oversight and management of team of medical record coding auditors
Analyze and make a determination of appropriate reimbursements and/or modifications of Coding review guidelines in partnership with medical directors and clinical staff.
Contribute to new business readiness through comprehensive coding audit requirements
Review bulletins, newsletters, periodicals and attend workshops to stay abreast of current issues and trends, changes in laws and regulations governing medical record coding and documentation
Develop and update procedures to maintain standards for correct medical record auditing or coding to minimize the risk of fraud, waste, abuse and error
Provide expertise in regard to analytic software and coding which requires knowledge of coding/reimbursement/policy
Provide oversight of documenting code editing solutions, testing and promotion of changes following established departmental change management processes
Oversee research of analysis of data in relation to code edits and to draw conclusions to resolve issues as it relates to edits, including participation on provider calls
Consult in predictive analytic modeling refinement to drive lower false positives
Monitor and manage applicable departmental expenses based on current year’s budget
Generate and maintain reportable QAI savings for the department and report combined annual savings based on vendor and line of business
Provide oversight and expertise of reimbursement methodology pertaining to Ambulatory Procedural Coding (APC), Diagnosis Related Groupers (DRG) and Outpatient Prospective Payment System (OPPS) as well as professional claim reimbursement
Responsible for hiring, coaching, development and performance management of staff
Perform any other job duties as requested