Vice President, Payment Integrity

Gainwell Technologies LLC•Any city, OH

5d•$156,100 - $223,000•Remote

About The Position

The VP, Payment Integrity is responsible for developing high-quality business strategies and operational plans ensuring alignment with Gainwell short-term and long-term objectives for the solution offering. Overseeing all related payment integrity delivery operations to ensure they produce the desired results and are consistent with the overall product line goals driving revenue growth, margin expansion and client satisfaction. The VP should be able to lead and motivate team members to advance employee engagement, develop a high-performing managerial team along with partnering cross functionally with broader organization such as Finance, Account Management, Sales and Engineering, and Implementations.

Requirements

At least fifteen years of gradually increasing product, finance and/or operational leadership experience.
Experience working within the payer side of the healthcare industry required, experience with Medicaid preferred.
At least five years of leadership experience required in payment integrity operations.
Familiarity with AI interventions leading to revenue acceleration and cost reduction strongly preferred.
Strong interpersonal and influence skills to cultivate relationships, facilitate negotiations, and build partnerships with customers and key stakeholders.
Strong strategic management, product management, planning, operational and analytical skills with proven experience working in complex organizations.

Nice To Haves

Familiarity with AI interventions leading to revenue acceleration and cost reduction strongly preferred.

Responsibilities

Pre-payment and post-payment versions of the following solutions: Clinical Claim Reviews (DRG Audit, Itemized Bill Review, Place of Service, Utilization Review) and Payment Analytics/Data Mining. Portfolio also includes FraudCapture, Utilization Review, Long-Term Care, and Credit Balance.
Responsible for developing, managing and attaining revenue and expense budget goals.
Partnering with technical development partners to manage overall product portfolio development plan progress in alignment with client need and revenue budgeting and forecasting process.
Responsible for monitoring systems and processes that identify and mitigate opportunities/risks to the payment integrity revenue portfolio.
Advanced financial analysis and forecasting techniques to project and optimize revenue.
Collaborating with VP Product and tracking opportunities for product expansion and in support of annual product revenue expansion targets.
Partnering with the AI development team to build and maintain a pipeline of AI development projects designed to improve efficiencies, accelerate growth and achieve faster go to market solutions within the payment integrity portfolio.
Represent the company in pre-sales solutioning efforts when payment integrity solutions are under consideration. Work with Gainwell SGMs and HMS SVP Client Management to collaboratively design solutions which align within the HMS product portfolio and roadmap.
Partner with clinical operations team on demand, capacity, and assuring compliance with client SLAs and contract requirements.
Oversee reviews of RFPs and new business proposals to assure they meet appropriate guidelines for strategic fit as well as implementation, operational and financial success.
Improves product quality through a structured process of defect identification, root cause analysis, and corrective action project management.
Improves internal product processes through deployment of Lean or other AI driven continuous quality improvement methodologies and principles.
Manage staffing planning and WFM tools across entire delivery team to ensure revenue goals are exceeded and there are zero production days lost due to lack of staffing.
Builds and maintains a comprehensive suite of operational metrics related to PI service efficiency and effectiveness, including quality, cost per unit, audit and review productivity, staffing to demand, appeals, appeals OT, and analytics efficacy as expressed in true positive rate.
Manage close coordination with product implementation team accountable for solution architecture design and end to end project management of new implementations.
Participates with Solution Area Leader in communicating product strategy, financial results, operational status and quality/compliance issues to company leadership.
Leads PI delivery teams by developing an environment of engagement and participation by all team members through regular communication, recognition and quarterly Town Hall meetings.
Directs development and training of leadership skills within the team to assist team members in increasing their skill sets, developing bench strength and appropriate success plans.
Becomes a Talent Management champion by participating in required talent and succession management review sessions.