Senior Manager, Payment Integrity

This is a fully remote position, open to applicants in Arizona, +16 more states.

📋 Description

• Lead teams that are accountable for conducting prepayment and post-payment waste/error reviews, as well as managing primary and secondary editing vendors.

• Ensure that provider claims are paid accurately.

• Report findings, trends, and month-over-month savings to senior leadership.

• Analyze vendor savings and identify areas of medical cost leakage.

• Communicate team outcomes and drive enhancements in prepayment solutions, recoveries, claims payment accuracy, adjustment volumes, provider service, financial liabilities, and provider billing patterns.

• Oversee the successful implementation of new payment-integrity processes and vendor partnerships.

• Develop, oversee, and report on departmental goals and metrics.

• Manage coaching, meetings, issue resolution, performance measurement, recruitment, retention, reviews, morale, recognition, and staff development.

• Establish and uphold departmental policies, procedures, swim lanes, and vendor processes.

• Maintain executive reporting and conduct monthly, quarterly, and annual analyses of findings and savings.

• Report overpayments or suspected fraud/abuse to the Special Investigations Unit.

• Enhance processes through automation and increased efficiency.

• Supervise savings and recovery initiatives and recover overpayments through retrospective data analysis.

• Identify root causes, influence stakeholders, champion process improvements, and improve claims-editing solutions.

• Manage relationships with claims processing teams and vendors.

• Stay informed about corporate policies, regulatory codes, legislative directives, and guidelines.

• Act as a subject matter expert for both internal and external customers.

• Manage or participate in assigned projects and educate customers on processes, content, and trends.

• Collaborate with pharmacy operations, payment intent/cost containment, network management, SIU, claims operations, clinical services, operations audit, and internal audit.

⛳️ Requirements

• Bachelor's degree or equivalent experience in a related field.

• 7+ years of work experience beyond obtaining the degree.

• 5+ years of experience in people leadership roles.

• 4+ years of experience in reimbursement policy.

• Primary home address must be in a state where Medica is registered as an employer: AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI.

• Must be legally authorized to work in the United States at the time of application.

• Medica does not provide work visa sponsorship for this position.

🏝️ Benefits

• Competitive medical, dental, and vision benefits.

• Paid time off (PTO).

• Holidays.

• Paid volunteer time off.

• 401K contributions.

• Caregiver services.

• Incentive plan compensation may be available in addition to base salary.