Director of Payment Integrity (Hybrid)

TheDirector of Payment Integrity will lead efforts in the identification and implementation of cross functional opportunities resulting in operational efficiency, claim payment accuracy and adherence to industry standard medical claim cost containment practices. Initiatives will be delivered via internal operational processes and performance management as well with the use of external vendors. This leadership position is accountable for timely and clear communication of opportunities/key findings, outcomes, and improvement opportunities to all impacted business partners and cross functional teams, including claim operations, clinical and medical claim coding, configuration, compliance, network operations and financial teams at a variety of leadership levels.

Job Duties & Responsibilities:

• Provide leadership to ensure that the operations are managed in a manner that enhances and supports our ability to deliver meaningful cost savings through payment accuracy of claims without degradation to Medica's member or provider experience.
  
  • Set and manage to throughput and turnaround times, which meet and exceed customer SLAs and expectations.
  • Continuously improve productivity and operational efficiency in payment accuracy delivery.
  • Create and manage productivity metrics, efficiencies and claim payment accuracy.
  • Establish procedures and processes to ensure service and production's smooth functioning.
• Direct assigned operational functions to meet financial savings goals.
  
  • Assist with short-term and long-range planning and budget development to support strategic business goals.
  • Partner with other key stakeholders to develop savings validation and measurement methodology.
  • Drive savings innovation working sessions and corresponding validation efforts; coordinating proposed reimbursement policy opportunities and contract language initiatives when required.
• Design, implement and manage appropriate technological infrastructure and operational workflow processes to maximize value and ensure claims are paid correctly.
  
  • Interfaces with and coordinates well with IT, claim processing functions, other payment integrity delivery organizations, and Finance to deliver results. Break down barriers, fund and oversee automation/new tools development and re-engineer processes.
• Lead and manage the claims cost containment area in support of all lines of business, ensuring resources are secured to effectively manage internal operations/ inventory and oversight of vendors.
• Work collectively with Operations leadership and other key stakeholders to drive and ensure continued alignment with claims payment processes and other enterprise processes impacted by said programs and process (e.g., claims, customer service, contracts/billing, etc.)

Critical Skills/Specialized Knowledge:

• Strong Healthcare Payment Integrity/Accuracy knowledge
• Demonstrated ability to assemble teams and develop talent
• Demonstrated experience running production-oriented business operations
• Demonstrated experience as an active participant in corporate decision making at a senior level.
• Ability and capacity to provide practical as well as strategic leadership and lead employee engagement.
• Experience in driving organizational development and change.
• Strong project management and process improvement skills.
• Strong analytical and problem-solving skills
• Highly developed interpersonal skills and the ability to communicate effectively at all levels of the organization

Requirements:

• Bachelor's degree or equivalent work experience (6+ years mid-senior level)/MBA preferred
• 3+ years direct supervisory/management experience
• At least 10 years' experience in the areas of medical claims payment cost containment or payment integrity
• Clinical and/or healthcare claims operational experience strongly preferred
• Knowledge of claims payment standards and regulations set forth by the National Association of Insurance Commissioners (NAIC) and state and federal regulations, including but not limited to Section 111, Medicare Payment Demand, Medicare Secondary Payer Group Health Plan Requirements, workers compensation, PIP/accident
• Strong communication skills
• Strong experience creating, presenting, and reporting outcomes to executive leadership
• Experience with IT capability development to drive and enable operational and vendor solutions
• Demonstrated ability to develop and implement new strategies and encourage others to do the same
• Understanding of how to set, measure and adjustment organization metrics/key performance indicators
• Experience identifying, evaluating, implementing, and overseeing vendor solutions

This position requires COVID-19 vaccination per Medica's Employee COVID-19 Vaccination Policy. If you are hired, you would be expected to be fully vaccinated for COVID-19 prior to starting the position, unless a medical or religious exemption is needed. Medica is an Equal Opportunity Employer and provides reasonable accommodations in compliance with the ADA and Title VII.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)