Director, Payment Integrity
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
This position is responsible for leading the execution of payment integrity strategy and activity across the organization. Time is focused on business group and vendor oversight, with secondary time on enterprise-wide engagement. Primary duties include operational planning and oversight, as well as resource, relationship, and people management. This position provides input into strategic plans for the broader organization.
Essential Position Functions
Directs operational payment integrity activities across the organization in support of all lines of business. This includes post and pre-pay audit functions, payment recovery processes, COB, Subrogation, medical record review as well as fraud, waste and abuse activities.
Leads the execution of strategic initiatives, plans, and goals in alignment with organizational vision and goals.
Ensures payment integrity processes are in compliance with Federal and state regulatory and contractual requirements.
Provides oversight and ensures updated policies and procedures are maintained across Operations.
Designs, implements, and oversees a robust operations and vendor quality review audit program to meet corporate and strategic goals; presents audit results to include root cause, trend analysis and prepares remediation recommendations on a regularly scheduled basis; monitors remediation activities for effectiveness.
Ensures payment integrity productivity, financial and quality targets are established, measured, and reported.
Establishes business cadence (weekly, monthly, quarterly business reviews) to ensure results are met and/or exceeded.
Prepares and presents on the progress of Payment Integrity capability-building.
Effectively uses business intelligence and data analytics to monitor operations and identify cross functional process improvement opportunities.
Instills work culture of continuous process improvement, innovation, and quality.
Oversees the development and implementation of cross-functional operations improvements including standardization and controls design to ensure planned results are delivered
May serve as a sponsor or chair for key projects and initiatives involving Payment Integrity.
Oversees Payment Integrity projects and implementation.
Oversees multiple Payment Integrity vendor relationship(s) and performance, including enrollment premium vendors.
Identifies cost effective technologies, workflows and sourcing partnerships necessary to meet strategic commitments.
Develops payment integrity inventory tracking and staff forecasting tools.
Participates in the development of vision, goals, and strategic plans for Payment Integrity.
Develops short and long-term plans and policies; oversees the development and execution of standard operating procedures
Provides input into the strategic plans of the organization
Maintains a business unit view while establishing department priorities, being cognizant of broader business unit and organizational impacts
Recommends budgets in alignment with short and long-term plans
Manages resources to ensure priorities are accomplished
Approves resource allocations within budget, including people, finances, and timelines; make decisions on exceptions
Develops comprehensive business case for budget variance requests to include ROI analysis; ensures approval for budget variances as required.
Leads effective communication system for work group(s), ensuring a collaborative culture.
Builds and ensures effective relationships across internal teams and external organizations for current or future integration.
Works cross-functionality with internal and external stakeholders in identifying and driving projects, process improvement initiatives, and operational efficiencies.
Works closely with senior leadership, peers, and cross-department leadership providing programmatic, organizational, and technical support to ensure effective collaboration and integration of Payment Integrity functions.
Represents CareOregon in external meetings and functions, providing productive leadership presence and effectiveness.
Leads weekly, monthly and quarterly business review meetings with vendors and executive management as appropriate.
Ensures sufficient and effective training for payment integrity and quality review staff, including cross-training opportunities
Directs team(s) and establishes team and individual management goals
Provides team members with ongoing understanding of business unit plans and expectations
Performs employment functions in collaboration with Human Resources, including staffing, recruitment, performance management, professional development, and termination
Coaches, motivates, and recognizes staff
Creates opportunities for professional development
Leads the development of performance goals, measurement, and evaluation of results
Ensures participation in required training initiatives and organizational activities, as well as adherence to external regulations and internal policies
Drives a culture of success in alignment with the organizational mission, vision, and values
Drives process improvement initiatives; small scale and large scale
Knowledge, Skills and Abilities Required
Ability to produce superior results in a financial performance-oriented environment
In depth understanding of claims processing, within a managed health care or health insurance business model
Extensive knowledge of Medical, Behavioral Health, Dental and Pharmacy billing and coding
Detailed knowledge of Medicaid and Medicare requirements
Knowledge of managed care and health plan concepts, principles, practices and operations
Proficient in developing operations Key Performance Indicator metrics
Proficient computer skills, including Microsoft Excel and Word
Skilled in budget development and management
Strong financial analysis and risk management skills
Consensus building skills; ability to influence others without direct authority and negotiate favorable outcomes
Ability to take complex ideas and processes and communicate them in a clear and concise manner
Familiarity with building and managing internal operational quality review programs
Ability to balance strategic and operational priorities, and proactively identify and resolve operational barriers and issues
Ability to effectively manage, lead and engage internal teams in the fulfillment of roles and responsibilities, as well as strategic partners
Ability to communicate effectively, both verbally and in writing; strong presentation skills
Ability to effectively convey business unit goals and plans ensuring integration into strategic plans and initiatives
Ability to create and develop strategic partnerships with multiple stakeholders both internally and externally
Leadership competencies in designing, developing and implementing process structure, tools and measurement indicators that drive operational results
Ability to recognize process deficiencies and recommend and implement improvements
Ability to think analytically, apply analytical techniques and to provide in-depth analysis and recommendations to senior management using critical thinking and sound judgement
Ability to work in an environment with diverse individuals and groups
Ability to operate within a changing environment
Education and/or Experience
Minimum 10 years’ health operations experience, including a minimum of 8 years of progressively responsible experience in various functions of Payment Integrity, such as claims editing, enrollment, coordination of benefits, overpayment identification, claims auditing, pharmacy, Fraud, Waste and Abuse, and health care subrogation / third party liability
Minimum 3 years’ experience managing people leaders in a payment integrity or operations capacity
Minimum 8 years’ experience in managed care or health insurance industry
Large scale project oversight experience
Financial management experience
Experience with Tableau or Power BI
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.
Equipment: General office equipment and/or mobile technology
Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
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