Location:

Work from home (Pennsylvania)

Shift:

Days (United States of America)

Scheduled Weekly Hours:

40

Worker Type:

Regular

Exemption Status:

Yes

Job Summary:

The Prepayment Program Integrity Manager is responsible for the strategic and operational management of prepayment claims auditing programs designed to ensure payment and vendor accuracy. This role oversees prepayment review activities, vendor edit programs, provider appeal processes, and related auditing operations. The Manager leads a multidisciplinary team of clinical, coding, and audit professionals while partnering with internal stakeholders and external vendors to optimize claim review performance, cost savings opportunities, and provider engagement. This position is accountable for ensuring that prepayment audit activities are conducted in a consistent, compliant, fact-based, and unbiased manner while balancing payment integrity objectives with provider experience and operational efficiency.

Job Duties:

Manages day to day operations of Program Integrity Department. Ensures compliance with all federal, state, and other regulations while maintaining the integrity of all auditing data and reports. Conducts periodic compliance and performance reviews of auditor cases and activity. Improves the balance of complexity versus-value to increase potential impact and returns. Successfully promotes and ensures audits are fact based, unbiased, comprehensive, and provides comprehensive informative findings.

Key Responsibilities

Program Leadership & Operations

• Manage the daily operations of the Prepayment Program Integrity function, including prepayment claim review and vendor edit oversight.
• Develop, implement, and continuously improve prepayment auditing strategies that support organizational payment integrity and compliance objectives.
• Monitor program performance, audit outcomes, operational metrics, and financial impact to drive continuous improvement.
• Establish and maintain policies, procedures, workflows, and controls related to prepayment claims auditing activities.
• Prioritize and manage multiple initiatives while meeting regulatory requirements, business objectives, and operational deadlines.

Vendor Management & Oversight

• Serve as the primary business owner for prepayment audit vendors and editing solutions.
• Oversee vendor performance, service delivery, operational effectiveness, contractual obligations, and financial outcomes.
• Collaborate with vendors to implement new edits, optimize existing auditing strategies, and improve program results.
• Monitor vendor accuracy, consistency, turnaround times, and appeal outcomes through ongoing quality assurance and performance reviews.
• Lead regular business reviews and ensure vendor activities align with organizational goals and compliance standards.

Audit & Claims Review Management

• Oversee prepayment claim auditing activities involving professional, facility, and ancillary claims.
• Ensure audit methodologies, clinical reviews, and coding determinations meet industry standards and regulatory requirements.
• Evaluate audit results, identify trends, and recommend corrective actions to improve payment accuracy and reduce improper payments.
• Promote fact-based, objective, and defensible audit determinations supported by clinical and coding documentation.
• Conduct periodic reviews of audit performance, quality findings, and operational effectiveness.

Appeals & Provider Engagement

• Manage the prepayment audit appeal process and ensure timely, consistent, and compliant resolution of provider disputes.
• Partner with clinical, legal, compliance, provider relations, and operations teams to support appeal review and determination processes.
• Analyze appeal trends and outcomes to identify opportunities for audit refinement, provider education, and policy improvement.
• Ensure appeal decisions are supported by clinical evidence, coding guidelines, contractual requirements, and regulatory standards.

Clinical & Coding Team Leadership

• Lead and develop a team of nurses, coders, auditors, analysts, and payment integrity professionals.
• Provide guidance, coaching, and performance management to support staff development and operational excellence.
• Ensure team members maintain current knowledge of coding standards, reimbursement methodologies, payment integrity practices, and applicable regulations.
• Foster collaboration across clinical, coding, compliance, and operational teams.

Compliance & Risk Management

• Ensure all prepayment auditing activities comply with federal and state regulations, CMS requirements, contractual obligations, and organizational policies.
• Serve as a subject matter expert on payment integrity, prepayment auditing, coding compliance, and audit governance.
• Support internal and external audits, regulatory inquiries, and compliance reviews.
• Identify emerging risks, industry trends, and opportunities to strengthen prepayment controls and payment accuracy programs.

Reporting & Analytics

• Develop and present executive-level reporting on audit performance, savings, provider behavior changes, appeal outcomes, and vendor effectiveness.
• Analyze complex audit data and operational trends to support strategic decision-making.
• Provide recommendations to senior leadership regarding program enhancements, vendor optimization, and future payment integrity initiatives.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

*Relevant experience may be a combination of related work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years).

#LI-REMOTE

Position Details:

Preferred Qualifications

• Bachelor's Degree in Nursing, Health Information Management, Healthcare Administration, Business Administration, or related field; equivalent experience may be considered.
• 5+ years of experience in Payment Integrity, Claims Auditing, Healthcare Compliance, SIU, Program Integrity, or Revenue Integrity.
• 3+ years of leadership experience managing clinical, coding, audit, or payment integrity teams.
• Experience managing prepayment review programs and external audit vendors.
• Knowledge of healthcare reimbursement methodologies, claims processing, and payment integrity best practices.

Preferred Experience

• Registered Nurse (RN), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or similar credential.
• Experience with commercial, Medicare, and Medicaid claim auditing.
• Knowledge of fraud, waste, and abuse prevention programs.
• Experience managing provider appeals and dispute resolution processes.
• Strong understanding of medical coding, clinical validation, utilization management, and healthcare regulatory requirements.

Education:

High School Diploma or Equivalent (GED)- (Required)

Experience:

Minimum of 7 years-Relevant experience* (Required), Minimum of 2 years-Managerial/Supervisory (Required)

Certification(s) and License(s):

Skills:

Analytical Thinking, Communication, Computer Coding, Critical Thinking, Fraud Detection And Prevention, Fraud Management, Insurance Industry, Leadership

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.