Payment Integrity Program Manager

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

📋 Description

• Manage designated inpatient Payment Integrity programs, encompassing audit, appeals, quality, and review procedures across internal teams, offshore support, and external vendors.

• Ensure accuracy in audits, adherence to timelines, quality in coding and clinical assessments, compliance with regulations, consistency, and defensibility.

• Conduct complex and escalated inpatient Payment Integrity audits, which include clinical validation, DRG coding validation, readmission assessments, and hospital bill audit evaluations.

• Offer clear and defensible rationales and conclusions for audits.

• Provide direction and oversight to both internal teams and external vendors through calibration sessions, feedback loops, education, and ongoing quality assessments.

• Create and maintain specialized training materials, audit guidelines, review standards, and supporting documentation for the program.

• Execute quality reviews and trend analyses of coding, clinical, and audit outcomes.

• Track program metrics, dispute trends, and vendor performance; identify root causes and promote continuous improvement initiatives.

• Collaborate with internal and external stakeholders to address complex issues related to audits, coding, clinical matters, and escalations.

• Act as the primary subject matter expert in the assigned program areas.

• Assist in the management of disputes and appeals, including escalation reviews, audit rationale evaluations, and corrective action planning.

• Contribute to the implementation of new audit concepts, review methodologies, and program enhancements.

⛳️ Requirements

• 2-3 years of experience in healthcare auditing, Payment Integrity, coding review, clinical documentation assessment, or compliance.

• Strong knowledge of clinical and inpatient coding is essential.

• Required qualifications include CCS, RHIA, RHIT, RN, or equivalent inpatient coding/clinical validation experience.

• Strong preference for candidates with demonstrated expertise in inpatient DRG coding and validation.

• Proven experience in inpatient DRG assignment and validation, including ICD-10-CM coding, principal and secondary diagnosis assignment, MCC/CC identification, POA indicators, inpatient clinical documentation review, severity of illness/risk of mortality concepts, and readmission logic.

• Experience in reviewing medical records for audit accuracy, coding/clinical correctness, compliance, and defensibility is a must.

• Familiarity with structured audit programs, applying established criteria, documenting rationale, and ensuring consistency and quality in audit outcomes.

• Ability to interpret clinical and/or coding documentation to support audit decisions and address documentation gaps or discrepancies.

• Experience in collaboration across clinical, coding, audit, and operational teams in a complex healthcare setting.

• Strong analytical capabilities for evaluating audit trends, root causes, and documentation gaps.

• Demonstrated operational discipline with the ability to stay organized amid diverse responsibilities.

• Proven experience in training related to payment integrity audits.

• A Bachelor’s Degree is preferred.

• Excellent leadership, communication, and interpersonal skills are essential.

• Experience in managing offshore vendors is a plus.

• Capability to manage multiple priorities and meet deadlines in a dynamic environment.

• A sense of curiosity and practical experience with AI tools, automation, or LLM-based workflows in operational contexts.

🏝️ Benefits

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

• Generous paid time off policy.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

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

• Commission eligibility for Sales positions.

• Parental leave program offered.

• 401K program available.