JOB DESCRIPTION Job Summary

Leads and manages team responsible for payment integrity activities including recovery operations. Responsible for performance, quality levels and establishing procedures and techniques that achieve optimal payment integrity operational standards and production targets.

Essential Job Duties

• Leads and manages day-to-day operations for assigned payment integrity programs, ensuring accuracy, timeliness, and adherence to policies and procedures.
  • Hires, trains, and develops staff responsible for inventory management, reporting, data integrity, and recovery performance.
  • Implements and monitors quality assurance programs and performance metrics to ensure recovery and cost avoidance targets are met.
  • Collaborates with internal departments (Shared Services) to resolve system or process issues impacting payment accuracy.
  • Reviews and refines workflows and standard operating procedures to improve efficiency, accuracy, and audit readiness.
  • Facilitates meetings with vendors and internal partners to discuss production performance, operational barriers, and process optimization opportunities.
  • Analyzes operational data to identify trends, evaluate recovery effectiveness, and propose actionable improvements.
  • Supports compliance with CMS and state regulations.
  • Contributes to small- to mid-scale projects focused on process improvement, automation, and data accuracy.
  • Promotes a culture of accountability, continuous improvement, and professional development within the team.

Required Qualifications

• At least 7 years of experience supporting health care operations, including 4 years payment integrity/claims experience, or equivalent combination of relevant education and experience.
  • At least 1 year management/leadership experience.
  • Ability to establish and maintain positive and effective work relationships with coworkers, members, providers and customers.
  • Strong organizational and time-management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
  • Strong verbal and written communication skills.
  • Microsoft Office suite and applicable software program(s) proficiency.

Preferred Qualifications

• Managed care payor experience, preferably with Medicare/Medicaid government-sponsored programs.
  • Understanding of ICD-9/10CM, MS-, AP- and APR-DRG reimbursement.
  • Electronic medical record (EMR) and medical record repository experience.