Manager, Payment Integrity Auditing

This is a fully remote position, open to applicants in Alaska, +26 more states.

📋 Description

• Lead a team of Clinical Coding and Payment Integrity Auditors.

• Oversee audit programs focused on payment integrity to ensure claims reimbursement is both accurate and compliant.

• Design and implement audit strategies encompassing DRG validation, itemized bill assessments, level of care evaluations, hospital readmission audits, and various pre-payment and post-payment initiatives.

• Track audit performance and manage both internal and vendor audit operations.

• Recognize billing and payment trends, utilizing data-driven insights to enhance payment accuracy and minimize inappropriate healthcare expenditures.

• Direct the development of work products associated with payment integrity auditing processes and systems.

• Set team priorities, define project scopes, implement activities, conduct analytical work, and assign responsibilities.

• Recruit, mentor, oversee, and assess staff; offer feedback, coaching, and opportunities for professional growth.

• Convey strategic direction to team members and other departments within Premera.

• Provide guidance on complex payment integrity challenges and claim evaluations.

• Promote continuous improvement, innovation, and teamwork.

• Collaborate with leadership to ensure activities align with organizational strategies, objectives, and compliance standards.

⛳️ Requirements

• Bachelor's Degree or 8 years of relevant professional experience.

• 5 years of analytical experience in a technical, healthcare, or business-related field.

• 3 years of experience in leading medium to large-scale payment integrity projects.

• Certified Professional Coder designation or 6 years of experience in payment integrity.

• 6 years of familiarity with Premera's healthcare claims processing system or provider billing and revenue cycle management systems (preferred).

• 2 years of experience in hospital bill audits, including DRG validation and/or itemized bill assessments (preferred).

• Current Registered Nurse (RN) license (preferred).

• Advanced experience in claim auditing, appeals, payment integrity, and data mining (preferred).

• Experience in COB, post-pay data mining and auditing, pre-payment editing and auditing, subrogation, and FWA/SIU (preferred).

• Proficient in Microsoft Office Suite: Outlook, Word, Excel, PowerPoint.

• Experience in building and maintaining professional relationships with internal staff, external vendors, legal teams, and state and federal agencies.

• Outstanding analytical, written communication, verbal communication, presentation, and problem-solving abilities.

• Capability to meet the stated physical requirements with or without accommodations.

🏝️ Benefits

• Medical, vision, and dental coverage with low employee premiums.

• Voluntary benefit options, including pet insurance.

• Life and disability insurance.

• Retirement plans, including a 401K employer match and a pension plan vested after 3 years of service.

• Wellness incentives featuring mental well-being resources, counseling services, stress management programs, and mindfulness training.

• Generous paid time off.

• Tuition assistance for undergraduate and graduate programs.

• Employee recognition initiatives.

• Commuter benefits.

• Complimentary convenient on-site parking.

• Subsidized on-campus dining options.

• Health and wellness activities conducted on-site.

• Fitness and well-being center offering both in-person and virtual workouts, as well as nutritional counseling.