Role Description The Manager of Payment Integrity (PI) leads the strategic design, implementation, and execution of programs aimed at improving payment accuracy and enhancing member affordability. This role serves as a key liaison for reimbursement policy and PI initiatives, ensuring alignment between cost-of-care objectives and departmental priorities through structured governance, ideation, and business case development. The Manager oversees program-level performance tracking to ensure measurable impact and continuous improvement. In close collaboration with Health Care and Finance divisions, this role supports enterprise-wide cost-of-care strategies by identifying operational efficiencies, uncovering savings opportunities, and fostering innovative partnerships that expand the reach and effectiveness of PI initiatives. - Leads the development and execution of enterprise-wide Payment Integrity strategies aligned with financial and operational goals. - Oversees a comprehensive suite of pre- and post-payment programs—including claims editing, audits, subrogation, readmission reviews, and coordination of benefits. - Continuously refines approaches to address evolving trends such as value-based care, regulatory shifts, and emerging fraud schemes. - Manages external vendors supporting audits, analytics, and fraud detection. - Ensures accountability through robust service-level agreements (SLAs), key performance indicators (KPIs), and contract negotiations. - Monitors and reports on recovery rates, audit turnaround times, and dispute resolution outcomes. - Directs Fraud Waste and Abuse (FWA) detection efforts in collaboration with Special Investigations Unit (SIU) and compliance teams. - Leverages predictive analytics and rules engines to identify suspicious billing patterns. - Ensures compliance with ICD-10, CPT/HCPCS, DRG, and CMS guidelines to support accurate coding and reimbursement. - Serves as a subject matter expert on complex coding issues and documentation standards. - Integrates Payment Integrity efforts with care quality initiatives, targeting avoidable readmissions and preventable complications. - Maintains compliance with CMS, Medicaid, ACA, and state-specific regulations. - Leads audit responses and represents the organization in national forums. - Champions the adoption of Artificial Intelligence (AI), machine learning, and automation in audit workflows and fraud detection. - Pilots emerging technologies and integrates them into core operations. - Collaborates with IT and analytics teams to enhance data infrastructure and reporting capabilities. - Partners across Claims Operations, Finance, Provider Relations, Compliance, IT, and Care Management to embed Payment Integrity throughout the organization. - Translates complex technical concepts into actionable insights for diverse stakeholders. - Responsible for oversight, management, development, implementation, and communication of department programs. - Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. - Develop annual department budgets and monitor spending versus the planned budget throughout the year. - Coordinate business activities by maintaining collaborative partnerships with key departments. - Responsible for process improvement and working with other departments to improve interdepartmental processes. - Actively participate as a key team member in Manager/Supervisor meetings. - Actively participate in various strategic and internal committees. Qualifications - A minimum of 5 years of progressive experience in healthcare operations. - Expertise in claims processing, clinical coding, reimbursement strategies, and/or fraud prevention required. - Demonstrated success in strategic planning, vendor oversight, and cross-functional collaboration. - Bachelor’s degree required. Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience will also be considered. - Preferred area of focus: Healthcare Operations, Statistics, or a related field. Requirements - Proven track record of leading operational initiatives from concept through execution. - Deep expertise in managed care claims coding, including CPT, ICD, HCPCS, Revenue Codes. - Comprehensive understanding of federal and state Medicaid payment regulations. - Proficient in Excel and SQL, leveraging data analysis to drive informed business decisions. Benefits - Base Range: $90,052.16 - $157,591.26 Environment - Work inside in a general office setting with ergonomically configured equipment. - Travel is required approximately 10% of the time. Skills - Accountable leadership - Collaboration - Data-driven & Analytical - Delegation - Effective communication - Listening (active) - Situational Leadership - Strategic Thinking Physical Requirements - Stoop and bend. - Sit and/or stand for extended periods of time while performing core job functions. - Repetitive motions to include typing, sorting and filing. - Light lifting and carrying of files and business materials. - Ability to read and comprehend both written and spoken English. - Communicate clearly and effectively. Disclaimer This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.