Manager, Payment Integrity Auditing

Workforce Classification:
Telecommuter
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As the Manager of Payment Integrity Auditing , you will lead a team of Clinical Coding and Payment Integrity Auditors and oversee the organization's payment integrity audit programs to ensure claims are reimbursed accurately and in compliance with contract provisions, payment policies, coding standards, clinical guidelines, and regulatory requirements. This role is responsible for developing and executing audit strategies across multiple audit types, including DRG validation, itemized bill reviews, level of care reviews, hospital readmission audits, and other post-payment and pre-payment audit initiatives. You will monitor audit performance, oversee internal and vendor audit activities, identify payment and billing trends, and leverage data-driven insights to improve payment accuracy, reduce inappropriate healthcare expenditures, and strengthen the organization's overall payment integrity strategy.

This is a remote/telecommuter position working from home.
What you’ll do:

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Manage a team of clinical coding and payment integrity auditors, ensuring high performance and professional development.

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Direct work products that are primarily related to payment integrity auditing processes and systems and provide recommendations to coordinate and optimize those processes and systems.

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Establish team priorities - determine scope of projects, implementation, analytical work, and responsibilities of team.

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Hire, develop, supervise, and evaluate staff; provide employees with timely feedback and coaching regarding performance at regular intervals and professional development opportunities through work assignments, special projects, further education, and feedback.

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Communicate strategic direction of the payment integrity auditing program, to both staff and other Premera departments.

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Provide guidance on complex payment integrity issues, claim reviews, and ensure timely execution of payment integrity auditing activities.

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Foster a culture of continuous improvement, innovation, and collaboration within the team and across departments.

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Collaborate with leadership to align payment integrity activities with organizational strategies, goals, and compliance requirements.

What you’ll bring:
Required Qualifications

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Bachelor's Degree or (8) years of relevant work experience.

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(5) years of analytical experience in a technical, healthcare, or business-related discipline, including (3) years of experience leading medium to large-size payment integrity projects.

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Certified Professional Coder designation or (6) years of payment integrity experience.

Preferred Qualifications

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(6) years of experience with Premera's health care claims processing system or provider billing and revenue cycle management systems.

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(2) years of experience with hospital bill audits (DRG validation and/or itemized bill review).

- Current Registered Nurse (RN) license.

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Advanced claim auditing, appeals, payment integrity, and data mining experience.

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Experience across all payment integrity disciplines: COB, post-pay data mining and auditing, pre-payment editing and auditing,