Payment Integrity Program Development Manager

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

📋 Description

• Oversee the complete lifecycle of edit and audit development, from the initial coding and billing hypothesis to the intricate design of rules.

• Transform intricate medical policies, CMS regulations, AMA/CPT guidelines, and coding standards into actionable logic specifications, detailing exact conditions, exclusions, thresholds, and flags.

• Capable of executing data queries to validate the financial soundness of a coding and billing hypothesis and drafting the corresponding technical specification document.

• Formulate payment policies where CMS guidance requires enhancement to ensure defensibility in supporting the underlying concept.

• After release, enhance concept effectiveness, reduce false positives, and minimize provider friction, continuously refining active rules based on real-world outcomes and updated behavioral patterns.

• Leverage large language models (LLMs) or automated pattern-matching tools to analyze claim trends and create narratives, expediting the conversion of signals into active payment logic.

• Directly link identified billing anomalies to published primary defense sources, such as CMS guidelines, NCCI bundling frameworks, LCD/NCD rules, and AMA coding requirements.

• Strategically plan, organize, and coordinate specific initiatives and concepts to achieve measurable payment accuracy objectives and timelines.

• Collaborate with PI Directors, internal auditors, SIU, and claims operations to ensure the appropriateness of coding and billing, compliance with regulations, and alignment of cross-functional strategies.

⛳️ Requirements

• Bachelor's degree and at least 4 years of relevant professional experience within a health plan, payment integrity vendor, or healthcare revenue cycle setting.

• Established subject matter expertise as a coding and billing regulations specialist, with extensive knowledge in interpreting CMS policies (LCDs, NCDs, LCAs), NCCI bundling edits, and provider manuals.

• Proven experience and comfort with developing logic concepts, including a solid history of writing logic rules or structural guidelines for claims processing implementation.

• Demonstrated capability to plan, organize, and coordinate individual concepts and initiatives, employing strong problem-solving skills to overcome operational challenges and adhere to deadlines.

• Strong analytical skills with the ability to read, interpret, and validate data query scripts or advanced spreadsheets to verify edit efficacy and assess coding and billing hypotheses.

🏝️ Benefits

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

• Generous paid time off.

• $100 monthly mobile or internet stipend.

• Stock options available for all employees.

• Bonus eligibility for all positions except Director and above; commission eligibility for Sales roles.

• Parental leave program.

• 401K program.