Clinical Coding Director, Payment Integrity

Role Overview

• The Director, Payment Integrity uses technology and data mining, detects anomalies in data to identify and collect overpayment of claims.
• The Director leverages technology and the clinical and coding expertise of their associates to identify potential overpayments to be substantiated via review of medical records.
• The Director contributes to the investigations of fraud, waste and abuse.
• The Director requires an in-depth understanding of how organizational capabilities interrelate across the function or segment.
• The Clinical and Coding Medical Record Review Director of Payment Integrity contributes to overall cost reduction, by increasing the accuracy of provider payments in our payer systems, and by ensuring correct claims payment.
• The Director oversees internal teams and stacked vendor operations conducting reviews of inpatient and outpatient services using automation, new innovative technology and expertise.
• The Director will make decisions related to the implementation of new/updated programs or large-scale projects.
• The Director will lead Operations for technical procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance.

Requirements

• Bachelor's degree in business, healthcare administration, clinical, information systems, or a related field
• 5 or more years of proven management experience in a healthcare or claims related field (Ideally leading large-scale operations)
• Proven experience and ability to determine the needed approach, resources, and goals to meet business objectives and execute quickly
• Excellent communication and presentation skills to include the ability to communicate and present technical details to Senior level leadership and/or Senior Government officials
• Ability to work with project stakeholders, contracting, providers, IT, enterprise partners, clinical leaders at all levels in the organization in a collaborative, team environment
• Strong business acumen and proven experience analyzing complex metrics and making high impact data driven decisions
• Exceptional Operational experience ideally working within a large matrixed organization and multiple systems/tech stacks
• Critical thinker who can anticipate team needs and take initiative to present ideas, ask the right questions and deliver the highest quality work
• Experience with facilitating, consulting, and delivering complex concepts
• Strong computer & technology skills (e.g. Excel, Word, PowerPoint with an interest in learning and applying AI capabilities and applications and other programs required for assimilating and presenting reports)
• Strong understanding of Human Resource principles and aligning talent with key components of our business strategy to create value for all stakeholders
• Self-starter who takes initiative and ownership and anticipates future consequences and trends accurately
• Ability to apply knowledge of new technology, artificial intelligence applications and business management concepts to improve operations
• Ability to manage multiple tasks, priorities and deadlines with attention to detail

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance and many other opportunities