Responsible for developing, implementing, and continuously improving enterprise-wide payment integrity and claims programs and strategies
Overseeing monitoring, analysis, and reporting of claims activity (e.g., trends, outliers, high-cost claims)
Managing development and maintenance of tracking mechanisms, dashboards, and documentation related to audits, findings, and overpayment recoveries
Ensure accurate invoicing and reconciliation for programs and vendors; oversee processing of recoupments and refunds
Identifying root causes of overpayments, track trends, and drive corrective actions with accountable owners
Building business cases and ROI models to expand initiatives, resources, and technology enabling sustainable savings and improved accuracy
Establish governance, KPIs, and reporting cadence for program performance, savings, recoveries, and risk mitigation
Leading a portfolio of coding audits, ensuring accurate capture of diagnosis and procedure codes in claims and chart review data
Developing and delivering training and education for providers and internal stakeholders

Minimum 5 years’ management experience in health plan claims operations, audit, and/or payment integrity
Minimum 5 years’ experience as a certified coder and/or Certified Coding auditor with active certification AHIMA or AAPC (e.g., CPC, CCS, CCA, CMC or equivalent)
Preferred experience performing statistical claims analysis in a managed care or health care setting
Experience in and/or understanding of payment integrity programs and vendors
Experience with SQL Server Reporting, or using business intelligence tools (e.g., Tableau) and data framework

medical, dental, vision, life, AD&D, and disability insurance
health savings account
flexible spending account(s)
lifestyle spending account
employee assistance program
wellness program
discounts
multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pet insurance)
retirement plan with employer contributions
PTO and Paid State Sick Time based on hours worked/scheduled hours
paid holidays, volunteer time, jury duty, bereavement leave

Payment Integrity Coding Manager

Key skills