2/28/2022

Job Description:

We invite you to use your skills and experience to make a difference in the lives of our members and our partner coordinated care organizations!  Do you enjoy exploring parks, wineries, trails, rafting, and more? Join our team!!

We are hiring IMMEDIATELY for a Director of Payment Integrity to join one of our community mental health providers!

Job Summary:

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.

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 clinical reviews.
  • 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.
  • Oversee payment integrity vendor performance, as well as vet new payment integrity vendor offerings/expansions.

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.

Employee Supervision

  • Directs team(s) and establishes team direction and goals in alignment with the organizational mission, vision, and values.
  • Identifies work and staffing models; recruits, hires, and oversees a team to meet work needs, using an equity, diversity, and inclusion lens.
  • Identifies department priorities; ensures employees have information and resources to meet job expectations.
  • Leads the development, communication, and oversight of team and individual goals; ensures goals, expectations, and standards are clearly understood by staff.
  • Manages, coaches, motivates, and guides employees; promotes employee development.
  • Incorporates guidance from equity tools into people leadership, planning, operations, evaluation, budgeting, resource allocation, and decision making.
  • Ensures team adheres to department and organizational standards, policies, and procedures.
  • Evaluates employee performance and provides regular feedback to support success; recognizes strong performance and addresses performance gaps and accountability (corrective action).
  • Performs supervisory tasks in collaboration with Human Resources as needed.

Knowledge, Skills and Abilities Required

  • Strong understanding of claims processing, including medical, subrogation, COB processing, and benefits, preferably within a managed health care or health insurance business model
  • Understanding of claims fee schedule methodology for healthcare
  • Knowledge of Medical, Behavioral Health, Dental and Pharmacy billing and coding
  • Knowledge of managed care and Medicare health plan concepts, principles, practices, operations and requirements
  • Ability to produce superior results in a financial performance-oriented environment
  • 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 quality review methods for operations transactions
  • 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

Required:

  • Minimum 10 years’ health operations experience, including a minimum of 4 years’ 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 4 years’ experience in a supervisory position

Preferred:

  • Minimum 8 years’ experience in managed care or health insurance industry
  • Coding certification
  • Large scale project oversight experience
  • Financial management experience
  • Tableau or Power BI experience

“Careers and companies flourish when staff, clients, and candidates truly believe in the mission, know the role they play, and humbly reflect, evaluate, and act for the best interest of the communities served”