Manager, Payment Integrity – Readmission

This is a fully remote position, open to applicants in Florida, +2 more states.

📋 Description

• Leads a team of auditors and clinical professionals, ensuring the quality, consistency, and overall performance of the audit program related to potentially preventable readmissions.

• Manages payer readmission review initiatives, guaranteeing accurate and compliant decisions while meeting payment integrity goals.

• This position is responsible for guiding the identification and validation of potentially preventable readmissions, supporting appropriate reimbursement aligned with MS-DRG and APR-DRG methodologies.

• Drives program outcomes through oversight of audits, trend analysis, and the creation of standardized review criteria and best practices.

• Works collaboratively with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams to assist in the design, execution, and ongoing evaluation of strategies related to readmissions and DRG Payment Integrity.

• Evaluates program performance against established metrics, financial objectives, and operational benchmarks, applying trend analysis to uncover risks, variances, and areas for enhancement.

• Provides leadership and operational guidance to teams conducting readmission, MS-DRG, and APR-DRG reviews, ensuring accuracy, consistency, timeliness, and compliance with established review standards.

• Ensures adherence to federal and state regulations, managed care organization requirements, contractual commitments, and internal policies governing Payment Integrity and audit activities.

• Prepares and delivers reports, analyses, and performance summaries to leadership and key stakeholders, emphasizing audit results, trends, and actionable recommendations.

• Identifies operational risks, process gaps, and control weaknesses, implementing or suggesting corrective measures to enhance quality, efficiency, and program effectiveness.

• Guides, mentors, and develops team members by establishing clear expectations, encouraging accountability, and nurturing a collaborative culture focused on quality and continuous improvement.

• Acts as a subject matter expert on Payment Integrity practices within the designated scope, offering insights on readmission review methodologies, audit standards, and reimbursement considerations.

⛳️ Requirements

• A Bachelor’s degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or a related field is required; alternatively, an additional four (4) years of relevant experience may be considered instead of a degree.

• A minimum of 5 years of progressive experience in Payment Integrity, including readmission review and DRG validation activities, is required.

• At least 3 years of experience in people leadership, including direct team management, is required.

• A minimum of 2 years of experience utilizing Diagnosis Related Group encoder and grouper tools (such as 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, Payment Systems Incorporated, or similar tools) is required.

• Experience with payer claims systems is preferred.

• Proven experience in supporting government programs, regulatory compliance, or audit activities is preferred.

• Project management experience is preferred.

• Experience collaborating with external vendors on Payment Integrity audit, recovery, or edit programs is preferred.

• Inpatient hospital documentation improvement experience is preferred.

• Active Health Information Management or coding credentials, such as RHIT, RHIA, CCS, CIC, or CCDS, or Registered Nurse licensure or higher clinical qualifications combined with a coding credential, are required.

🏝️ Benefits

• Health insurance

• 401K and stock purchase plans

• Tuition reimbursement

• Paid time off plus holidays

• Flexible work options including remote, hybrid, field, or office work schedules