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Director, Payment Integrity and Claims Payment Integrity Manager Job in Portland, Oregon

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Job Title: Director, Payment Integrity and Claims Payment Integrity Manager

Skills:clinical coding,payment integrity,auditing
Preferred Certifications:CCS,CMC,CPC,CCA
Location:315 SW 5th Ave Portland 97204, OR, US
Date Posted:10/5/2020


Are you excited to step into a complex world that requires a blend of mind, heart and flexibility? We at CareOregon have been strengthening communities since 1994 by making health care work for everyone. As a nonprofit health plan largely focused on Oregon’s Medicaid population, we find fulfillment in supporting the underserved.

Director, Payment Integrity

General Statement of Duties

This position is responsible for leading the execution of payment integrity strategy and activity across the organization. Time is focused on business group and vendor oversight, with secondary time on enterprise-wide engagement. Primary duties include operational planning and oversight, as well as resource, relationship, and people management. This position provides input into strategic plans for the broader organization.

Essential Position Functions

Technical/Operational Leadership

·         Directs operational payment integrity activities across the organization in support of all lines of business. This includes post and pre-pay audit functions, payment recovery processes, COB, Subrogation, medical record review as well as fraud, waste and abuse activities.

·         Leads the execution of strategic initiatives, plans, and goals in alignment with organizational vision and goals.

·         Ensures payment integrity processes are in compliance with Federal and state regulatory and contractual requirements.

·         Provides oversight and ensures updated policies and procedures are maintained across Operations.

·         Designs, implements, and oversees a robust operations and vendor quality review audit program to meet corporate and strategic goals; presents audit results to include root cause, trend analysis and prepares remediation recommendations on a regularly scheduled basis; monitors remediation activities for effectiveness.

·         Ensures payment integrity productivity, financial and quality targets are established, measured, and reported.

·         Establishes business cadence (weekly, monthly, quarterly business reviews) to ensure results are met and/or exceeded.

·         Prepares and presents on the progress of Payment Integrity capability-building.

·         Effectively uses business intelligence and data analytics to monitor operations and identify cross functional process improvement opportunities.

·         Instills work culture of continuous process improvement, innovation, and quality.

·         Oversees the development and implementation of cross-functional operations improvements including standardization and controls design to ensure planned results are delivered

·         May serve as a sponsor or chair for key projects and initiatives involving Payment Integrity.

·         Oversees Payment Integrity projects and implementation.

·         Oversees multiple Payment Integrity vendor relationship(s) and performance, including enrollment premium vendors.

·         Identifies cost effective technologies, workflows and sourcing partnerships necessary to meet strategic commitments.

·         Develops payment integrity inventory tracking and staff forecasting tools.

Strategic/Operational Planning

·         Participates in the development of vision, goals, and strategic plans for Payment Integrity.

·         Develops short and long-term plans and policies; oversees the development and execution of standard operating procedures

·         Provides input into the strategic plans of the organization

·         Maintains a business unit view while establishing department priorities, being cognizant of broader business unit and organizational impacts

Financial/Resource Management

·         Recommends budgets in alignment with short and long-term plans

·         Manages resources to ensure priorities are accomplished

·         Approves resource allocations within budget, including people, finances, and timelines; make decisions on exceptions

·         Develops comprehensive business case for budget variance requests to include ROI analysis; ensures approval for budget variances as required.

Relationship Management

·         Leads effective communication system for work group(s), ensuring a collaborative culture.

·         Builds and ensures effective relationships across internal teams and external organizations for current or future integration.

·         Works cross-functionality with internal and external stakeholders in identifying and driving projects, process improvement initiatives, and operational efficiencies.

·         Works closely with senior leadership, peers, and cross-department leadership providing programmatic, organizational, and technical support to ensure effective collaboration and integration of Payment Integrity functions.

·         Represents CareOregon in external meetings and functions, providing productive leadership presence and effectiveness.

·         Leads weekly, monthly and quarterly business review meetings with vendors and executive management as appropriate.

People Management

·         Ensures sufficient and effective training for payment integrity and quality review staff, including cross-training opportunities

·         Directs team(s) and establishes team and individual management goals

·         Provides team members with ongoing understanding of business unit plans and expectations

·         Performs employment functions in collaboration with Human Resources, including staffing, recruitment, performance management, professional development, and termination

·         Coaches, motivates, and recognizes staff

·         Creates opportunities for professional development

·         Leads the development of performance goals, measurement, and evaluation of results

·         Ensures participation in required training initiatives and organizational activities, as well as adherence to external regulations and internal policies

·         Drives a culture of success in alignment with the organizational mission, vision, and values

·         Drives process improvement initiatives; small scale and large scale

Knowledge, Skills and Abilities Required

·         Ability to produce superior results in a financial performance-oriented environment

·         In depth understanding of claims processing, within a managed health care or health insurance business model

·         Extensive knowledge of Medical, Behavioral Health, Dental and Pharmacy billing and coding

·         Detailed knowledge of Medicaid and Medicare requirements

·         Knowledge of managed care and health plan concepts, principles, practices and operations

·         Proficient in developing operations Key Performance Indicator metrics

·         Proficient computer skills, including Microsoft Excel and Word

·         Skilled in budget development and management

·         Strong financial analysis and risk management skills

·         Consensus building skills; ability to influence others without direct authority and negotiate favorable outcomes

·         Ability to take complex ideas and processes and communicate them in a clear and concise manner

·         Familiarity with building and managing internal operational quality review programs

·         Ability to balance strategic and operational priorities, and proactively identify and resolve operational barriers and issues

·         Ability to effectively manage, lead and engage internal teams in the fulfillment of roles and responsibilities, as well as strategic partners

·         Ability to communicate effectively, both verbally and in writing; strong presentation skills

·         Ability to effectively convey business unit goals and plans ensuring integration into strategic plans and initiatives

·         Ability to create and develop strategic partnerships with multiple stakeholders both internally and externally

·         Leadership competencies in designing, developing and implementing process structure, tools and measurement indicators that drive operational results

·         Ability to recognize process deficiencies and recommend and implement improvements

·         Ability to think analytically, apply analytical techniques and to provide in-depth analysis and recommendations to senior management using critical thinking and sound judgement

·         Ability to work in an environment with diverse individuals and groups

·         Ability to operate within a changing environment

Education and/or Experience


·         Minimum 10 years’ health operations experience, including a minimum of 8 years of progressively responsible experience in various functions of Payment Integrity, such as claims editing, enrollment, coordination of benefits, overpayment identification, claims auditing, pharmacy, Fraud, Waste and Abuse, and health care subrogation / third party liability

·         Minimum 3 years’ experience managing people leaders in a payment integrity or operations capacity


·         Minimum 8 years’ experience in managed care or health insurance industry

·         Large scale project oversight experience

·         Financial management experience

·         Experience with Tableau or Power BI

Working Conditions

·         Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

Veterans welcome to apply

Claims Payment Integrity Manager

General Statement of Duties

The Claims Payment Integrity Manager is responsible for guiding the development and implementation of programs and strategies to ensure the Plan’s corporate claims editing and payment policies meet the strategic goals of the plan. Oversight is enterprise-wide, spanning all CareOregon regions and lines of business. The position requires effective alignment and integration with multiple internal teams, including Legal, Audit, Compliance, Finance, Data Analytics and Network. This position facilitates a coordinated plan of action across internal and external stakeholders.

This position also ensures downstream provider payment appeal activities consistently adhere to corporate policies. This position is responsible for developing and growing the Claims Payment Integrity initiative by developing strong business case scenarios that justify team expansion and growth. He/she will understand the compliance requirements posed by our relationship with the State and CMS regulatory agencies and help ensure regulatory requirements are met.

Essential Position Functions

Claims Analysis and Standards

·         Individually monitors, analyzes and reports claims information including relevant health care trends and high cost claims by segment.

·         Lead staff in monitoring, analyzing, and reporting on claims activity, including relevant health care trends and high cost claims by segment.

·         Work with Plan departments to develop and oversee standard operating procedures to ensure consistency in business rules applied in claim adjudication.

·         Review claims, hospital bills, and physician notes and data to devise and refine procedures for identifying and resolving billing errors and provider billing practices.

·         Work with the health plan provider team and the auditing team to develop ongoing processes for auditing provider bills, recording errors and tracking collections.

·         Work closely with data analysts, clinical operations, technical, legal and operational teams to create sustainable and scalable cost savings solutions.

·         Performs variance analysis, assists with medical claims reconciliation and payment process development/improvement.

·         Publishes various reports and presentations.

·         Aligns with fraud waste and abuse reduction initiatives and leading resultant initiatives and projects.

·         Interface with various departments, management and individuals external to CareOregon.

·         Communicate findings and improvements with identified work groups, steering committee meetings and external auditors/partners.

·         Expand the scope of payments reviewed by using data analytics to find new opportunities.

·         Develop or expand performance metrics to assess the quality of our payments and their improvement over time.

Management and Leadership

·         Train, supervise and evaluate performance of assigned staff as needed

·         Provide staff with the training, mentoring and resources necessary to carry out their work

·         Ensure adherence to department and organizational standards, policies and procedures

·         Ensure performance goals, expectations and standards are clearly understood by supervised staff

·         Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration

·         Evaluate employees’ performance on an ongoing basis and take appropriate corrective action if needed

·         Perform human resource functions in collaboration with Human Resources

Knowledge, skills and abilities required

·         Demonstrated leadership ability to influence change and results

·         Ability to develop payment processes and solutions for low income, Medicaid, and Medicare populations

·         Comprehensive program development, management and evaluation skills

·         Strong understanding of State and Federal regulations that impact operations in order to properly respond

·         Knowledge and skills in claims system management, editing software, and coding

·         Statistical, analytical, problem solving, and organizational skills

·         Demonstrated ability to communicate effectively both verbally and in writing, possessing strong presentation skills

·         Skilled in negotiation and ability to build consensus

·         Excellent interpersonal skills

·         People leadership skills, including the ability to coach and mentor staff

·         Knowledge of how to confidently navigate through complex and challenging business issues

·         Ability to work effectively with a variety of individuals and groups related to the provision of services

·         Ability to use computer programs commonly used for health plan operations

·         Ability to present a positive and professional image

·         Demonstrated ability to maintain professional relationships with internal staff and departments

·         Ability to work well under pressure in a complex and rapidly changing environment

·         Ability to work in an environment with diverse individuals and groups

·         Ability to supportand comply with organizational policies, procedures and guidelines

Education and/or Experience


·         Minimum 5 years’ claims administration experience, including clinical coding


·         Experience performing statistical claims analysis in a managed care/health care setting

·         Clinical coding certification; examples include but are not limited to Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC) or Certified Coding Associate (CCA)

·         Minimum 2 years management experience, including developing and implementing processes and influencing others

·         Associate’s or Bachelor's Degree in Business, Statistics, Healthcare Administration, or related field

Working Conditions

·         Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

Veterans welcome to apply


To apply visit: <https://careoregon.org/careers>

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