Claims Payment Integrity Manager
Are you excited to step into a complex world that requires a blend of mind, heart and flexibility? We at CareOregon have been strengthening communities since 1994 by making health care work for everyone. As a nonprofit health plan largely focused on Oregon’s Medicaid population, we find fulfillment in supporting the underserved.
General Statement of Duties
The Claims Payment Integrity Manager is responsible for guiding the development and implementation of programs and strategies to ensure the Plan’s corporate claims editing and payment policies meet the strategic goals of the plan. Oversight is enterprise-wide, spanning all CareOregon regions and lines of business. The position requires effective alignment and integration with multiple internal teams, including Legal, Audit, Compliance, Finance, Data Analytics and Network. This position facilitates a coordinated plan of action across internal and external stakeholders.
This position also ensures downstream provider payment appeal activities consistently adhere to corporate policies. This position is responsible for developing and growing the Claims Payment Integrity initiative by developing strong business case scenarios that justify team expansion and growth. He/she will understand the compliance requirements posed by our relationship with the State and CMS regulatory agencies and help ensure regulatory requirements are met.
Essential Position Functions
Claims Analysis and Standards
Individually monitors, analyzes and reports claims information including relevant health care trends and high cost claims by segment.
Lead staff in monitoring, analyzing, and reporting on claims activity, including relevant health care trends and high cost claims by segment.
Work with Plan departments to develop and oversee standard operating procedures to ensure consistency in business rules applied in claim adjudication.
Review claims, hospital bills, and physician notes and data to devise and refine procedures for identifying and resolving billing errors and provider billing practices.
Work with the health plan provider team and the auditing 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.
Performs variance analysis, assists with medical claims reconciliation and payment process development/improvement.
Publishes various reports and presentations.
Aligns with fraud waste and abuse reduction initiatives and leading resultant initiatives and projects.
Interface with various departments, management and individuals external to CareOregon.
Communicate findings and improvements with identified work groups, steering committee meetings and external auditors/partners.
Expand the scope of payments reviewed by using data analytics to find new opportunities.
Develop or expand performance metrics to assess the quality of our payments and their improvement over time.
Management and Leadership
Train, supervise and evaluate performance of assigned staff as needed
Provide staff with the training, mentoring and resources necessary to carry out their work
Ensure adherence to department and organizational standards, policies and procedures
Ensure performance goals, expectations and standards are clearly understood by supervised staff
Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration
Evaluate employees’ performance on an ongoing basis and take appropriate corrective action if needed
Perform human resource functions in collaboration with Human Resources
Essential Department and Organizational Functions
Propose and implement process improvements
Meet deadlines for completion workload
Maintain agreed upon work schedule
Demonstrate cooperation and teamwork
Provide interdepartmental-training on specific job responsibilities
Work closely with analysts, clinical operations, technical, legal & operational teams to create sustainable & scalable cost savings solutions
Expand the scope of payments reviewed by using data analytics to find new opportunities
Meet identified business goals that contribute to departmental goals
Knowledge, skills and abilities required
Demonstrated leadership ability to influence change and results
Ability to develop payment processes and solutions for low income, Medicaid, and Medicare populations
Comprehensive program development, management and evaluation skills
Strong understanding of State and Federal regulations that impact operations in order to properly respond
Knowledge and skills in claims system management, editing software, and coding
Statistical, analytical, problem solving, and organizational skills
Demonstrated ability to communicate effectively both verbally and in writing, possessing strong presentation skills
Skilled in negotiation and ability to build consensus
Excellent interpersonal skills
People leadership skills, including the ability to coach and mentor staff
Knowledge of how to confidently navigate through complex and challenging business issues
Ability to work effectively with a variety of individuals and groups related to the provision of services
Ability to use computer programs commonly used for health plan operations
Ability to present a positive and professional image
Demonstrated ability to maintain professional relationships with internal staff and departments
Ability to work well under pressure in a complex and rapidly changing environment
Ability to work in an environment with diverse individuals and groups
Ability to support and comply with organizational policies, procedures and guidelines
Education and/or Experience
Minimum 5 years’ claims administration experience, including clinical coding
Experience performing statistical claims analysis in a managed care/health care setting
Clinical coding certification; examples include but are not limited to Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC) or Certified Coding Associate (CCA)
Minimum 2 years management experience, including developing and implementing processes and influencing others
Associate’s or Bachelor’s Degree in Business, Statistics, Healthcare Administration, or related field
Environment: This position’s primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):
☒ Inside/office ☐ Clinics/health facilities ☐ Member homes
Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.
Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment
Veterans are strongly encouraged to apply.
Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.Position Description »