Supervisor, Payment Integrity (Remote)

Molina Healthcare•Long Beach, AZ

4d•Remote

About The Position

Leads and supervises a team responsible for payment integrity activities, including recovery operations. The role is responsible for performance, quality levels, and establishing procedures and techniques to achieve optimal payment integrity operational standards and production targets. This position supports the implementation and execution of initiatives related to overpayment recovery, coordination of benefits (COB), subrogation, premium enhancement, datamining, pre-pay editing, and vendor management. The supervisor will hire, train, develop, mentor, and manage the team, ensuring they meet production targets and execute payment integrity programs effectively. This includes analyzing complex data, developing insights, and collaborating with leadership to resolve recovery issues and ensure compliance with regulatory requirements.

Requirements

At least 5 years of experience supporting health care operations, including 3 years payment integrity/claims experience, or equivalent combination of relevant education and experience.
Ability to establish and maintain positive and effective work relationships with coworkers, members, providers and customers.
Strong organizational and time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
Effective verbal and written communication skills.
Microsoft Office suite and applicable software program(s) proficiency.

Nice To Haves

Management/leadership experience.
Managed care payor experience, preferably with Medicare/Medicaid.
Understanding of ICD-9/10CM, MS-, AP- and APR-DRG reimbursement.
Electronic medical record (EMR) and medical record repository experience.

Responsibilities

Supports implementation and execution of initiatives including overpayment recovery, coordination of benefits (COB), subrogation, premium enhancement, datamining, pre-pay editing, and supplemental oversight and vendor inventory management.
Hires, trains, develops, mentors, and manages team responsible for inventory management, prioritization, information reporting, data management, quality control, and workflows.
Leads recovery processing, offset reconciliation, refund posting and reconciliation, provider dispute resolution, claim referrals, and health plan special projects.
Ensures team meets or exceeds production targets.
Executes payment integrity programs that prioritize, identify, and resolve payment/recovery issues.
Establishes procedures and techniques to achieve payment integrity operational standards.
Executes and monitors recovery inventory to ensure maintenance of performance and quality levels.
Demonstrates expertise in claims processing, claims payment issue resolution, payment/adjustment error troubleshooting, and quality controls recovery adjustments.
Professionally communicates and responds to health plan/provider inquiries and escalates issues as appropriate.
Manages inventory production queues, and assigns and prioritizes work.
Analyzes complex data-driven reports and develops actionable insights for resolution and leadership reporting.
Collaborates with payment integrity leadership to resolve recovery issues.
Executes tasks and projects to ensure Centers for Medicare and Medicaid Services (CMS) and state regulatory requirements are met for pre-pay edits, overpayment recovery, COB, and subrogation.