Corewell Health
Manager, Payment Integrity
Seeking a strategic and results-driven leader to join Priority Health as a Manager, Payment Integrity. This role is responsible for overseeing and executing enterprise-level initiatives that drive cost containment and ensure alignment across key business functions. The ideal candidate will bring deep expertise in healthcare operations and a strong command of project management principles. You will lead cross-functional efforts, ensuring interdependencies across Network Contracting, Utilization Management, and Billing Policy are effectively managed to support the organization's strategic and financial goals. Key responsibilities include: Providing strategic oversight and implementation leadership for cost containment initiatives. Ensuring alignment of business operations to achieve targeted outcomes. Applying rigorous project management methodologies to drive execution. Identifying and addressing savings gaps with innovative, data-driven solutions. Collaborating across departments to ensure financial targets are met and sustained. Responsible for management of all aspects of the Payment Integrity Program with specific expertise in healthcare payment and reimbursement. The Payment Integrity Manager is responsible for managing staff and associated activities to ensure that saving opportunities are initiated, executed, and reported. These efforts will support the organization's cost containment efforts specific to medical claims payment and drive payment integrity performance. This position is responsible for coordinating with organizational Executive leadership in setting the priorities, goals and objectives of the Payment Integrity program. Organization strategy will be supported by coordinating with Medical Policy and Provider Relations teams to effectively plan and execute program tactics. Manage the vendors that are hired to perform Universal program review and audit functions for Priority Health. Oversee all activities associated with delivering an audit service from Statement of Work (SOW) creation to delivery of contract terms. Identify risk associated with incorrect payment decisions, audit outcome impacts, provider impacts, compliance or other health plan obligation that might involve actions by a vendor or the vendor's program operation. Assure oversight of efficient and correct vendor data exchange through other employees who execute them. Essential Functions - Manager, Payment Integrity Develops an annual risk assessment and audit plan to support the organization's Payment Integrity Strategy. Develop/sustain and engagement model between the Claims integrity function and other business units within the organization. Collaborates with Medical, Pharmacy, and Provider teams to determine the best course of action to align policies supporting cost containment activities. Establishes process for case assignment to review and respond to Provider appeals. Knowledge and understanding of plan products, payment methodologies, medical and payment policies. Reviews and provides feedback on provider agreements, member materials, and other internal documents impacted by the Payment Integrity program. Interviews, hires and manages staff to best prioritize and coordinate work efforts supporting efficient and effective cost containment activities specifically related to medical claims payments. Assures claims are paid correctly according to primacy and liability rules. Updates internal systems correctly so that claims are paid correctly. Uses information from internal and external sources to properly determine if a system update is appropriate for claims to be paid correctly. Accountable for reporting accurate data and articulating savings. Controls the department COB Understands the impact of current programs on provider satisfaction, including volume of claim decision overturns that result from current program operations. Embraces "pay it correctly the first time" in the OPL (Other Plan Liability) internal functions. Builds a team of "industry experts" in OPL compliance for government business across the corporation. Improve membership and enrollment aspects of OPL, using best practices as a guide. Implement new processes to track primacy, evaluate the continued usefulness of Claim Extension Module and the ONBASE administrative module. Creates a devoted unit for COB and OPL, understanding how internal functions relate to savings potential and reality. Creates an efficient and effective operational unit. Meets timeliness standards to not delay claim processing in any case. Makes sure staff are meeting production expectations. Makes sure the quality program is adequately detecting errors and reporting quality results. Qualifications - Manager, Payment Integrity Required: Bachelor's Degree or equivalent in Healthcare, Nursing, or Business 5 years of relevant experience working with Healthcare claim auditing or equivalent combination of; auditing, medical coding, healthcare revenue cycle, or regulatory (i.e., CMS & Medicaid) experience 5 years of in-depth understanding of provider payment methodologies and concepts (DRGs, capitation, RBRVS payments, APC, percent of charges, etc.) 5 years of relevant experience working with State and Federal regulations related to healthcare billing and coding Experience with health care claims Preferred: Direct experience in hospital or physician billing, or equivalent experience with a managed care payer Experience working with government programs including Medicare, Medicaid and FEHB CRT - Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire or CRT - Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire or CRT - Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire or CRT - Coding Specialist, Certified - Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon or CRT - Professional Coder - AAPC American Academy of Professional Coders Upon Hire or CRT - Professional Coder, Certified - Payer (CPC-P) Upon Hire or CRT - Professional Coder, Certified - Hospital Outpatient (CPC-H) Upon Hire About Corewell Health As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.
Seeking a strategic and results-driven leader to join Priority Health as a Manager, Payment Integrity. This role is responsible for overseeing and executing enterprise-level initiatives that drive cost containment and ensure alignment across key business functions. The ideal candidate will bring deep expertise in healthcare operations and a strong command of project management principles. You will lead cross-functional efforts, ensuring interdependencies across Network Contracting, Utilization Management, and Billing Policy are effectively managed to support the organization's strategic and financial goals. Key responsibilities include: Providing strategic oversight and implementation leadership for cost containment initiatives. Ensuring alignment of business operations to achieve targeted outcomes. Applying rigorous project management methodologies to drive execution. Identifying and addressing savings gaps with innovative, data-driven solutions. Collaborating across departments to ensure financial targets are met and sustained. Responsible for management of all aspects of the Payment Integrity Program with specific expertise in healthcare payment and reimbursement. The Payment Integrity Manager is responsible for managing staff and associated activities to ensure that saving opportunities are initiated, executed, and reported. These efforts will support the organization's cost containment efforts specific to medical claims payment and drive payment integrity performance. This position is responsible for coordinating with organizational Executive leadership in setting the priorities, goals and objectives of the Payment Integrity program. Organization strategy will be supported by coordinating with Medical Policy and Provider Relations teams to effectively plan and execute program tactics. Manage the vendors that are hired to perform Universal program review and audit functions for Priority Health. Oversee all activities associated with delivering an audit service from Statement of Work (SOW) creation to delivery of contract terms. Identify risk associated with incorrect payment decisions, audit outcome impacts, provider impacts, compliance or other health plan obligation that might involve actions by a vendor or the vendor's program operation. Assure oversight of efficient and correct vendor data exchange through other employees who execute them. Essential Functions - Manager, Payment Integrity Develops an annual risk assessment and audit plan to support the organization's Payment Integrity Strategy. Develop/sustain and engagement model between the Claims integrity function and other business units within the organization. Collaborates with Medical, Pharmacy, and Provider teams to determine the best course of action to align policies supporting cost containment activities. Establishes process for case assignment to review and respond to Provider appeals. Knowledge and understanding of plan products, payment methodologies, medical and payment policies. Reviews and provides feedback on provider agreements, member materials, and other internal documents impacted by the Payment Integrity program. Interviews, hires and manages staff to best prioritize and coordinate work efforts supporting efficient and effective cost containment activities specifically related to medical claims payments. Assures claims are paid correctly according to primacy and liability rules. Updates internal systems correctly so that claims are paid correctly. Uses information from internal and external sources to properly determine if a system update is appropriate for claims to be paid correctly. Accountable for reporting accurate data and articulating savings. Controls the department COB Understands the impact of current programs on provider satisfaction, including volume of claim decision overturns that result from current program operations. Embraces "pay it correctly the first time" in the OPL (Other Plan Liability) internal functions. Builds a team of "industry experts" in OPL compliance for government business across the corporation. Improve membership and enrollment aspects of OPL, using best practices as a guide. Implement new processes to track primacy, evaluate the continued usefulness of Claim Extension Module and the ONBASE administrative module. Creates a devoted unit for COB and OPL, understanding how internal functions relate to savings potential and reality. Creates an efficient and effective operational unit. Meets timeliness standards to not delay claim processing in any case. Makes sure staff are meeting production expectations. Makes sure the quality program is adequately detecting errors and reporting quality results. Qualifications - Manager, Payment Integrity Required: Bachelor's Degree or equivalent in Healthcare, Nursing, or Business 5 years of relevant experience working with Healthcare claim auditing or equivalent combination of; auditing, medical coding, healthcare revenue cycle, or regulatory (i.e., CMS & Medicaid) experience 5 years of in-depth understanding of provider payment methodologies and concepts (DRGs, capitation, RBRVS payments, APC, percent of charges, etc.) 5 years of relevant experience working with State and Federal regulations related to healthcare billing and coding Experience with health care claims Preferred: Direct experience in hospital or physician billing, or equivalent experience with a managed care payer Experience working with government programs including Medicare, Medicaid and FEHB CRT - Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire or CRT - Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire or CRT - Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire or CRT - Coding Specialist, Certified - Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon or CRT - Professional Coder - AAPC American Academy of Professional Coders Upon Hire or CRT - Professional Coder, Certified - Payer (CPC-P) Upon Hire or CRT - Professional Coder, Certified - Hospital Outpatient (CPC-H) Upon Hire About Corewell Health As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.