RN Readmission Manager, Payment Integrity

This is a fully remote position, open to applicants in Arizona, +4 more states.

📋 Description

• Lead and manage Payment Integrity initiatives aimed at addressing potentially preventable readmissions, facilitating cost recovery, ensuring cost avoidance, and enhancing payment accuracy.

• Supervise a team of auditors and clinical experts while maintaining audit quality, consistency, and overall program performance.

• Oversee payer readmission review programs to ensure accurate and compliant determinations that align with payment integrity goals.

• Direct the identification and validation of potentially preventable readmissions utilizing MS-DRG and APR-DRG methodologies.

• Propel program outcomes through audit oversight, trend analysis, standardized review criteria, and the implementation of best practices.

• Collaborate effectively with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams.

• Track metrics, financial objectives, operational benchmarks, risks, variances, and opportunities for improvement.

• Provide operational oversight for readmission, MS-DRG, and APR-DRG review teams.

• Ensure adherence to regulations, managed care requirements, contracts, and internal policies.

• Prepare and deliver reports, analyses, and performance summaries to leadership and stakeholders.

• Identify process deficiencies, operational risks, and control weaknesses, implementing or recommending corrective actions.

• Lead, mentor, and develop team members.

• Act as a subject matter expert in Payment Integrity.

• Perform additional duties as assigned and comply with established policies and standards.

⛳️ Requirements

• An active Health Information Management or coding credential is required, such as RHIT, RHIA, CCS, CIC, or CCDS.

• A Registered Nurse licensure or a higher clinical qualification, combined with a coding credential, is required.

• A Bachelor’s degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or a related field is required; four additional years of directly related experience may be accepted in lieu of a degree.

• Over 5 years of progressive experience in Payment Integrity, including activities related to readmission review and DRG validation.

• More than 3 years of experience in people leadership, including direct management of teams.

• At least 2 years of experience with Diagnosis Related Group encoder and grouper tools such as 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, or Payment Systems Incorporated.

• Experience with payer claims systems is preferred.

• Background 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.

• A Master’s degree is preferred.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K plan.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off.

• Holidays.

• A flexible work approach with options for remote, hybrid, field, or office schedules.

• Additional incentives may be included in total compensation.