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Position Summary
 

The Claims Operations and Payment Integrity Leader is responsible for managing day-to-day operations of Claims Operations and Payment Integrity teams. The leader will be responsible in ensuring claims are processed accurately, efficiently, and in compliance with all regulatory and Martin’s Point policies. The role will also focus on preventing overpayments, identifying incorrect claims, and leading payment integrity recovery efforts in timely manner, while improving system controls and implementing automation to improve claims processing efficiency. The leader will partner closely with internal teams and external Payment Integrity vendors to optimize claims and payment integrity outcomes, while expanding cost containment capabilities, pre and post pay. This position will provide effective leadership to Claims Supervisors and Payment Integrity analysts encompassing hiring, leadership, coaching, counseling, communicating, mentoring, training, and creating a positive and cooperative working environment.

Job Description

 Key Outcomes:

• Ensures claims are adjudicated by maintaining high claims accuracy, ensuring regulatory compliance, and improving processing efficiency.

• Oversees the end-to-end claims adjudication processes and ensure claims are processed within Medicare and Tricare regulatory timeliness.
• Monitors claims volumes and productivity metrics and collaborate with Quality Assurance analysist to monitor claim processing accuracy through quality audits and ensure that Supervisors are implementing corrective actions for recurring claim errors and enforcing claims processing workflows/documented processes.
• Handles complex or escalated claims issues and collaborate with internal departments for timely resolution.
• Ensures and maintains compliance with Medicare, Tricare, and internal guidelines.
• Develops and oversees the organization’s payment integrity program aligns with industry standards, best practices, PI vendors to augment internal expertise and activities.
• Leads pre-payment and post-payment audits to identify overpayments, duplicate claims, and inappropriate billing and coding to ensure recovery efforts are processed timely and accurately.
• Utilizes data analytics and reporting tools to identify trends, root causes, and process improvement opportunities related to claim inaccuracies.
• Partners with Provider Relations, Finance, Compliance, and IT teams to improve claims processes, enhance automation, and ensure accuracy.
• Manages relationships with external payment integrity vendors, including contract management, performance monitoring, and validation/reconciliation of results.
• Ensures all payment integrity activities comply with Medicare and Tricare regulations, payer contracts, and internal policies.
• Identifies and implements best practices and system enhancements that improve the efficiency, accuracy, and integrity of payment integrity operations.
• Prepares and presents regular reports on all Payment Integrity initiatives/programs (internal and external) outcomes, savings, and performance metrics to senior leadership.
• Establishes, monitors, and continuously improves processes and supporting policies and ensure PI team complies with all internal policies/procedures.

Education/Experience

• Bachelor’s degree In Finance, Business Administration, Healthcare Management or related field required.
• 5 years management and/or leadership experience, with a focus on Payment Integrity, claims operations, healthcare auditing, or related roles.
• Experience managing industry standard PI vendor partnerships and contract performance

Skills/Knowledge/Competencies (Behaviors):

• Knowledge of claims policies and procedures, including industry standards from Medicaid, CMS, and CCI Edits
• Understanding of or experience with fraud, waste, and abuse investigatory techniques and strategies
• Solid understanding of standard claims processing systems, operations, and claims data analysis
• Knowledge of HIPAA privacy regulation and rules necessary
• Knowledge of CMS reimbursement methodology
• ighly developed quantitative and qualitative analytical skills
• Strong interpersonal skills, including professional communication, relationship building, and effective written and verbal communication
• Proficiency with Microsoft Office Suite applications
• Advanced skills in medical terminology, CPT/ICD-9/10 coding is preferred
• Ability to articulate goals, plan and implement processes, and meet deadlines

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact [email protected]

Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]