Payment Integrity Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct clinical reviews of inpatient admissions and related readmissions occurring within 30 days of a prior discharge, both prepayment and post-payment.

• Review medical records and claims to evaluate clinical relationships and the potential for consolidating or preventing readmissions.

• Implement organizational policies, regulatory requirements, readmission criteria, and relevant exclusions.

• Prepare clear, objective, timely, and defensible clinical rationales along with supporting documentation.

• Compile initial findings, responses to disputes, appeal letters, and review additional documentation for disputes or appeals.

• Collaborate with internal teams, such as Payment Integrity, appeals, quality, and utilization management, on complex or disputed cases.

• Engage in calibration sessions, peer reviews, quality assessments, and case discussions.

• Maintain precise records in clinical review and audit systems while safeguarding confidential information.

• Identify trends, issues in documentation, and opportunities to enhance the processes and outcomes of readmission reviews.

⛳️ Requirements

• A Registered Nurse degree with a current, active, and unrestricted RN license in at least one U.S. state.

• A minimum of five years of experience in clinical nursing, hospital care, healthcare auditing, Payment Integrity, utilization management, quality review, or a similar healthcare environment.

• Proven experience in reviewing inpatient hospital readmissions.

• In-depth knowledge of inpatient clinical care, disease processes, care complications, discharge planning, and transitions of care.

• Experience in reviewing medical records and synthesizing clinical information from various sources.

• Proficient in applying established clinical criteria, policies, regulatory guidance, and review methodologies.

• Strong skills in critical thinking, analysis, problem-solving, and attention to detail.

• Excellent written and verbal communication abilities.

• Familiarity with electronic medical records, claims information, clinical review systems, or audit workflow platforms.

• A Bachelor of Science in Nursing or a bachelor’s degree in a related healthcare field is preferred.

• Experience with Medicare, Medicaid, commercial payers, QIO, State Operations Manual, or payer-specific readmission criteria is preferred.

• Knowledge of inpatient coding, DRG methodology, clinical validation, or hospital bill audits is preferred.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plan with low or no premium.

• Generous paid time off.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all roles, excluding Director and above.

• 401K program.

• Parental leave program.