Director, Payment Integrity
CareOregon puts the care in health care. We are a nonprofit providing health insurance services to meet the health care needs of low-income Oregonians. We serve about one quarter of Oregon Health Plan members plus members in our Medicare plan.
Our mission is to inspire and partner to create quality and equity in individual and community health. Our vision is healthy communities for all individuals, regardless of income or social factors.
We focus on the total health of our members, not just traditional health care. In teaming up with members, their families and their communities, we help Oregonians live better lives, prevent illness and respond effectively to health issues.
To apply visit www.careoregon.org/careers and search for Vice President, Clinical Operations (19544). If you have any difficulty submitting your resume through the online process, please let us know by emailing email@example.com.
To protect the health and well-being of our members, employees and community, CareOregon requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious exception as a qualification of employment.
Candidates who receive an offer of employment by CareOregon, must provide proof of COVID-19 vaccination or submit a medical or religious exception request, which will be evaluated in accordance with CareOregon’s standard accommodation process.
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.
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 clinical reviews.
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.
Oversee payment integrity vendor performance, as well as vet new payment integrity vendor offerings/expansions.
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.
Directs team(s) and establishes team direction and goals in alignment with the organizational mission, vision, and values.
Identifies work and staffing models; recruits, hires, and oversees a team to meet work needs, using an equity, diversity, and inclusion lens.
Identifies department priorities; ensures employees have information and resources to meet job expectations.
Leads the development, communication, and oversight of team and individual goals; ensures goals, expectations, and standards are clearly understood by staff.
Manages, coaches, motivates, and guides employees; promotes employee development.
Incorporates guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, budgeting, resource allocation, and decision making.
Ensures team adheres to department and organizational standards, policies, and procedures.
Evaluates employee performance and provides regular feedback to support success; recognizes strong performance and addresses performance gaps and accountability (corrective action).
Performs supervisory tasks in collaboration with Human Resources as needed.
Perform work in alignment with the organization’s mission, vision, and values.
Support the organization’s commitment to equity, diversity, and inclusion by fostering a culture of open mindedness, cultural awareness, compassion, and respect for all individuals.
Strive to meet annual business goals in support the organization’s strategic goals.
Adhere to the organization’s policies, procedures, and other relevant compliance needs.
Perform other duties as needed.
Education and/or Experience
Minimum 10 years’ health operations experience, including a minimum of 4 years’ 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 4 years’ experience in a supervisory position
Minimum 8 years’ experience in managed care or health insurance industry
Large scale project oversight experience
Financial management experience
Tableau or Power BI experience
CareOregon is among the top-rated nonprofits in Oregon, noted especially for our work/life flexibility. We offer competitive salaries and generous benefits.
Salary will be discussed during the interview process.Position Description »