Payment Integrity Manager

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General Statement of Duties
The Claims Payment Integrity Manager is responsible for guiding the development and implementation of programs and strategies to ensure that CareOregon’s claims editing and payment policies meet the organization’s strategic goals. The position is responsible for enterprise-wide oversite, spanning all of CareOregon regions and lines of business. The position requires effective alignment and integration with multiple internal and external teams and stakeholders including, but not limited to, coordination between vendors, legal, audit, compliance, finance, data analytics and network operational functions.

This leader is responsible for developing and growing Payment Integrity initiatives by developing strong business case scenarios that justify team expansion and growth. They understand the compliance requirements posed by our relationship with the state of Oregon and Centers for Medicare and Medicaid Services (CMS) and help ensure regulatory requirements are met. This leader will also be responsible for managing our operations team audit program and user acceptance testing of any system changes.

Essential Position Functions

Payment Integrity Management

Produce accurate and timely reports of all Payment Integrity savings and forecasting.
Develop and maintain tracking mechanisms, reports and all relevant documentation related to audits and overpayment recoveries.
Track and identify audit finding trends and overpayment recoveries; identify root causes and communicate findings to appropriate departments and/or personnel.
Contribute directly in monitoring, analyzing and reporting claims activity including relevant health care trends and high cost claims by segment.
Lead staff in monitoring, analyzing, and reporting claims activity including relevant health care trends and high cost claims by segment.
Develop department metrics and performance standards; assist team in meeting or exceeding departmental performance standards.
Prepare and coordinate internal quarterly business reviews.
Publish various reports and presentations.
Oversee and ensure the accurate invoicing of all programs and vendors managed by Operations.
Monitor timely and accurate posting of refunds and processing of recoupments.
Monitor timely completion of audits and resolutions to disputes or rebuttals.
Stay abreast of all regulatory and/or contractual changes and communicate changes to staff.
Serve as the primary vendor contact and manage vendors conducting cost containment activities.

Quality and User Acceptance Testing

Manage a team of quality auditors responsible for testing the accuracy of transactional processing.
Track, trend and report on quality audit results on a weekly, monthly, quarterly and year-to-date basis.
Develop or expand performance metrics to assess the quality of our payments and their improvement over time.
Identify and recommend changes/enhancements to processes, processing guides and/or internal tools to achieve improved quality outcomes.
Develop, manage and schedule Operations user acceptance testing, scripting, playbooks and job aides.

Process Improvement

Work with CareOregon departments to develop and oversee standard operating procedures to ensure that consistent business rules are applied in claim adjudication.
Review claims, hospital bills, and physician notes and data to devise and refine procedures for identifying billing errors and resolving problematic provider billing practices.
Work with the Provider Relations team and the Audit and Compliance 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.
Use data analytics to find new opportunities to expand the scope of payments reviewed.
Perform variance analysis, assist with medical claims reconciliation and payment process development/improvement.
Align with fraud waste and abuse reduction initiatives and lead resultant initiatives and projects.
Develop and maintain department’s policies, procedures and workflows.
Develop training documents and conduct process trainings on a regular basis.
Identify opportunities for improvement and recommend solutions.

Essential Department and Organizational Functions
Propose and implement process improvements.
Meet deadlines for completion of workload.
Maintain agreed upon work schedule.
Demonstrate cooperation and teamwork.
Provide cross-training on specific job responsibilities.
Meet identified business goals that contribute to departmental goals.
Perform other duties as needed.

Management and Leadership

Train, supervise and evaluate performance of assigned staff.
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.
Evaluate employee performance on an ongoing basis; take appropriate corrective action if needed.
Perform human resource functions in collaboration with Human Resources

Knowledge, Skills and Abilities Required
Strong detail-orientation skills
Strong project management skills
Adept at prioritizing work
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
Statistical, analytical, problem-solving and organizational skills
Knowledge of how to confidently navigate through complex and challenging business issues
Working knowledge of different claims coding requirements and payment methodologies (e.g. PPS, Medicare fee schedules, etc.)
Knowledge of medical terminology
Knowledge and skill in claims system management, editing software, and coding
Excellent spoken, written and presentation communication skills
Ability to use computer programs commonly used for health plan operations
Ability to lead and influence change and results
Skill in negotiation and ability to build consensus
Skill in leading people, including the ability to coach and mentor staff
Excellent interpersonal skills
Ability to maintain professional relationships with internal and external staff and departments
Ability to work effectively with diverse individuals and groups related to the provision of services
Ability to present a positive and professional image as a leader and representative of CareOregon
Ability to work well under pressure in a complex and rapidly changing environment
Ability to support and comply with organizational policies, procedures and guidelines

Physical Skills and Abilities

Lifting/Carrying up to 10 Pounds

Pushing/Pulling up to 0 Pounds

Pinching/Retrieving Small Objects



Climbing Stairs

Repetitive Finger/Wrist/Elbow/

Shoulder/Neck Movement

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More than 6 hours/day








Speaking Clearly

0 hours/day

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More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

Cognitive and Other Skills and Abilities

Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

Education and/or Experience

Minimum 5 years’ management experience in claims operations, audit and/or payment recovery in a health plan setting
Minimum 5 years’ experience in claims examining and/or claims auditing

Experience performing statistical claims analysis in a managed care or health care setting
Clinical coding certification(s) including, but not limited to: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC) or Certified Coding Associate (CCA)
Experience in and/or understanding of payment integrity programs and vendors
Experience with SQL Server Reporting, or using business intelligence tools (e.g. Tableau) and data frameworks

Working Conditions
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

☐ Other_________________________________________

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
Hazards: n/a
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.

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