Manager, Payment Integrity
Location: Orange, California US
Job Number: 1921
Position Title: Manager, Payment Integrity
The Manager, Payment Integrity is responsible for the cost containment activities. The Manager is responsible for the daily management and monitoring of staff performing claims audit and overpayment recovery. The Manager collaborates with other department management and staff to identify root cause of overpayments and inaccuracies in payment processing. The Manager will play a vital role in the claims operations in ensuring cost containment activities are maximized. The Manager is responsible for implementing and facilitating controls of the audit and recovery processes which include development and implementation of policies and procedures, training programs and performing root-cause analysis and risk assessments.
Essential duties and responsibilities include but are not limited to:
1. Manages the day to day operations and processes around overpayment recoveries and claims audits (focused and/or random audits)
2. Provides direct support and leadership to the management and staff performing claims overpayment recoveries and audits
3. Develops and maintains department’s policies and procedures, workflows and training documents; conducts regular trainings
4. Develops department metrics and performance standards; assists team in meeting or exceeding departmental performance standards
5. Tracks and trends audit findings and overpayment recoveries; identifies root cause and communicates findings to appropriate departments and/or personnel
6. Identifies opportunities for improvement and recommends solutions
7. Monitors timely and accurate posting of refunds and processing of recoupments
8. Monitors timely completion of audits and ensures disputes or rebuttals are addressed timely
9. Collaborates with management team and other designated staff members in developing resolutions to identify issues or deficiencies
10. Develops and maintains tracking mechanisms, reports and all relevant documentation related to audits and overpayment recoveries
11. Ensures all cases are properly documented for reference and review
12. Conducts regular meetings with staff (department meetings and one-on-one) to ensure both departmental and individual performance are met
13. Stays abreast on all regulatory and/or contractual changes and communicates changes to staff
14. Responsible for managing vendors performing cost containment activities
15. Overall performance accountability (attendance, communication, flexibility, adaptability, interpersonal skills, teamwork and cooperation). Maintains a positive and productive work environment
16. Performs other related duties.
Oversees assigned staff. Responsibilities include: recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Minimum Experience:
• 5 years management experience in claims operations, audits and/or recovery in managed care setting
• 7+ years experience in claims examining and/or claims audits in HMO setting (preferably in Medicare Advantage delegated model)
• Bachelor’s degree in healthcare management or related field; and/or equivalent experience
• Knowledge of claims processing systems (EZCAP preferred) and claims audit tools
• Intermediate to Advance proficiency in MS Office products – Word, Access and Excel
• Comprehensive knowledge of Medicare Advantage claims processing requirements and other related regulatory requirements
• Working knowledge of different claims coding requirements and payment methodology (PPS, Medicare fee schedules, etc.)
• Knowledge of medical terminology
• Proven problem-solving skills and ability to translate knowledge to the department
• Strong organizational skills and decision-making and attention to details
• Ability to work well in a fast-paced and dynamic environment.
• Excellent presentation and training skills; group motivation and supervisory skills.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Location City: Orange
Location State: California
Community / Marketing Title: Manager, Payment Integrity
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