Manager, Payment Integrity – Recovery & Accounts Receivable

This is a fully remote position, open to applicants in Florida, +5 more locations.

📋 Description

• Develop, implement, and oversee strategic initiatives aimed at preventing fraud, waste, and abuse while adhering to state and federal regulations and tracking emerging trends and schemes.

• Lead the operations of Outstanding Claims Recovery and Accounts Receivable, taking responsibility for outstanding inventory, aging, collections, provider offsets/refunds, and financial recovery outcomes.

• Manage and nurture the team responsible for recovery and receivable functions, including prioritizing workloads, overseeing performance, coaching, and ensuring accountability for results.

• Spearhead complex recovery initiatives and Negative Balances projects, coordinating large cross-functional meetings with Claims, Finance, Provider/Network Operations, Health Plans, IT, and vendors.

• Establish and track operational metrics, controls, and reporting mechanisms to identify aging or stranded balances, manage collection risks, and enhance processes and technology.

• Lead teams of analysts in investigating potential fraud, waste, and abuse referrals.

• Monitor business processes and systems to ensure integrity and compliance in billing and claims payments.

• Develop tailored fraud plans to satisfy contract and federal requirements.

• Create educational materials to identify and validate waste activities as requested by the health plan and on an ad-hoc basis.

• Respond to RFP requests and enforce new policies according to contractual obligations.

• Attend state and federal meetings as mandated by specific contracts.

• Prepare and present the FWA program to state and federal personnel upon request, including during readiness reviews and after changes in state agency personnel.

• Review post-payment cases with relevant parties to secure refunds.

• Prepare and disseminate monthly and quarterly savings reports.

• Carry out additional duties as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Bachelor’s degree in Business, Healthcare, Criminal Justice, or a related field, or equivalent experience.

• A minimum of 4 years of experience in medical claim investigation, compliance, or fraud and abuse.

• Comprehensive knowledge of medical terminology is required.

• Previous experience in a managed care setting is preferred.

• Prior experience as a lead or supervisor of staff, including hiring, training, assigning tasks, and managing performance, is preferred.

• Experience overseeing staff responsible for recovery inventories, receivables, collections, or claims-related financial operations is preferred.

• Experience managing Outstanding Claims Recovery, Accounts Receivable, healthcare collections, provider recovery, or post-payment recovery operations is preferred.

• Experience handling large or aging financial inventories and formulating prioritization, escalation, and collection strategies is preferred.

• Familiarity with developing and monitoring operational and financial KPIs, such as inventory aging, recovery dollars, collections, productivity, and outstanding receivables, is preferred.

• Experience leading large cross-functional initiatives and stakeholder meetings involving Claims, Finance, Provider/Network Operations, IT, and external vendors is preferred.

• A medical records or coding license is preferred.

• Certifications such as Certified Revenue Cycle Representative (CRCR), Certified Revenue Cycle Professional (CRCP), or equivalent are preferred.

• Certification as a Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), or similar payment integrity certification is preferred.

• Project Management Professional (PMP) or comparable project/program management certification preferred.

• Other certifications related to health plan claims, payment integrity, accounts receivable, collections, or recovery operations are preferred.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work arrangements with options for remote, hybrid, field, or office schedules.

• Additional forms of incentives may be included in total compensation.

• Benefits may be subject to program eligibility.