Manager, Payment Integrity

Job Number: 1921

Workplace Type:

Position Title: Manager, Payment Integrity

External Description:

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.

General Duties/Responsibilities:

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.

Supervisory Responsibilities:
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.

Minimum Requirements:
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)

2. Education/Licensure:
• Bachelor’s degree in healthcare management or related field; and/or equivalent experience

3. Other:
• 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.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Manager, Payment Integrity

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].