Mgr, Payment Integrity

Corewell Health • $95K — $115K *
US-AnywhereRemote in Grand Rapids, MI
Healthcare
5 - 7 years of experience
Today
Be an Early Applicant
Job Overview by Ladders

Qualifications

  • Bachelor's Degree or equivalent in Healthcare, Nursing, or Business
  • 5+ years in healthcare claim auditing or related fields
  • In-depth knowledge of provider payment methodologies
  • 5+ years of understanding healthcare billing and coding regulations
  • Experience with health care claims
  • Preferred experience in hospital/physician billing or managed care

Responsibilities

  • Develop annual risk assessment and audit plans for the Payment Integrity Strategy
  • Create and maintain engagement models between Claims integrity and other business units
  • Manage audits of medical claims for billing appropriateness and recover funds as necessary
  • Collaborate with Medical, Pharmacy, and Provider teams to support cost containment
  • Establish processes for case assignment related to Provider appeals
  • Review and provide feedback on provider agreements and internal documents
  • Hire and manage staff to coordinate work related to medical claims payment

Benefits

  • Comprehensive benefits package for financial, health, and work/life balance
  • On-demand pay program through Payactiv
  • Discounts on restaurants, phone plans, and more
  • Optional identity theft protection and insurance
  • Retirement options with contributions and matching
Full Job Description
Job Summary

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.

Essential Functions

  • 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.
  • Manages and coordinates substantive audits of medical claims, done internally and externally, for appropriateness of billing and payment, including investigation of inappropriate bundling/unbundling of services, erroneous and duplicate billings, data-entry omissions and errors, and inappropriate payments. Accurately summarizes and report findings to coordinate Provider communication and recovery of funds.
  • 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.


Qualifications
  • Required Bachelor's Degree or equivalent Healthcare, Nursing, or Business
  • 5 years of relevant experience Healthcare claim auditing or equivalent combination of; auditing, medical coding, healthcare revenue cycle, or regulatory (i.e., CMS & Medicaid) experience Required
  • 5 years of relevant experience An in-depth understanding of provider payment methodologies and concepts (DRGs, capitation, RBRVS payments, APC, percent of charges, etc.) Required
  • 5 years of relevant experience Well versed with State and Federal regulations related to healthcare billing and coding Required
  • Experience with health care claims Required
  • Direct experience in hospital or physician billing, or equivalent experience with a managed care payer Preferred
  • Experience working with government programs including Medicare, Medicaid and FEHB Preferred
  • CRT-Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire preferred Or
  • CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire preferred Or
  • CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire preferred Or
  • CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire preferred Or
  • CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire preferred Or
  • CRT-Professional Coder, Certified - Payer (CPC-P) - UNKNOWN Unknown Upon Hire preferred Or
  • CRT-Professional Coder, Certified - Hospital Outpatient (CPC-H) - UNKNOWN Unknown Upon Hire preferred


Physical Demands

  • Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
  • Waist to Waist > 5 lbs: Seldom up to 10 lbs
  • Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
  • Waist to Overhead > 5 lbs: Seldom up to 10 lbs
  • Bilateral Carry > 5 lbs: Seldom up to 10 lbs
  • Unilateral Carry > 5 lbs: Seldom up to 10 lbs
  • Pushing Force > 5 lbs: Seldom up to 10 lbs
  • Pulling Force > 5 lbs: Seldom up to 10 lbs
  • Sitting: Frequently
  • Standing: Occasionally
  • Walking: Occasionally
  • Forward Bend - Standing: Seldom
  • Forward Bend - Sitting: Occasionally
  • Trunk Rotation - Standing: Seldom
  • Trunk Rotation - Sitting: Occasionally
  • Reach - Above Shoulder: Seldom
  • Reach - at Shoulder or Below: Seldom
  • Handling: Occasionally
  • Forceful Grip > 5 lbs: Seldom
  • Forceful Pinch > 2 lbs: Seldom
  • Visual Acuity ¹
    [None = No; Seldom = Yes]: Seldom

How Corewell Health cares for you
  • Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
  • On-demand pay program powered by Payactiv
  • Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
  • Optional identity theft protection, home and auto insurance
  • Traditional and Roth retirement options with service contribution and match savings
  • Eligibility for benefits is determined by employment type and status


Primary Location
SITE - Priority Health - 1239 E Beltline Ave NE - Grand Rapids

Department Name
Payment Integrity Value and Analysis - PH Managed Benefits

Employment Type
Full time

Shift
Day (United States of America)

Weekly Scheduled Hours
40

Hours of Work
8:00 - 5:00

Days Worked
Monday - Friday

Weekend Frequency
N/A

About Corewell Health

Corewell Health Careers

Joining Corewell Health presents an unparalleled opportunity to become part of a leading team of healthcare professionals dedicated to excellence. Corewell Health is renowned for its commitment to innovation, leadership, and providing superior healthcare services.

Explore Job Opportunities

Corewell Health is actively seeking talented individuals who are eager to contribute to a dynamic healthcare environment. The company offers a variety of job opportunities that cater to a range of skills and experiences. Whether you're a seasoned professional or a recent graduate, Corewell Health has a position that could be the perfect fit for your career ambitions.

Internship Programs

For those just starting their professional journey, Corewell Health provides robust internship programs designed to foster skills development and offer real-world experience in the healthcare industry. Internships at Corewell Health are a stepping stone to full-time employment and offer invaluable networking opportunities within the healthcare sector.

Growth and Development

Career growth is a cornerstone of employment at Corewell Health. The company supports its team members' professional development through comprehensive training programs, including leadership training and diversity training. These initiatives ensure that every team member has the tools and knowledge necessary to excel in their roles and advance within the company.

Benefits and Culture

Corewell Health is committed to creating a workplace culture that values diversity and inclusion. Employees enjoy a competitive package of benefits that supports both their professional and personal lives. The company's culture promotes teamwork and respect, making it an ideal environment for those who value collaboration and innovation.

Hiring Process

The hiring process at Corewell Health is designed to be transparent and efficient. Candidates are encouraged to submit a resume and may be invited for an interview to discuss their qualifications and career goals in more detail. Corewell Health values a thorough approach to ensure that all potential team members align with the company’s values and vision for the future.

Networking and Professional Development

Corewell Health believes in the power of networking and encourages its employees to engage with one another and the broader healthcare community. This engagement fosters a sense of community and collaboration, which is critical in the fast-paced world of healthcare.

Join the Team

Corewell Health is continuously looking for passionate, curious, and solution-driven individuals to join their ranks. Explore the open positions at Corewell Health by searching their Jobs and Careers page. Discover how your expertise and ambitions can contribute to the transformative work happening at Corewell Health.

Stay Connected

Keep up to date with the latest from Corewell Health by following their Careers Blog. Gain insights from insiders, learn more about the company culture, and stay informed about new job openings and company news.

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Personalize your subscription to receive job alerts and insider tips directly from Corewell Health. Tailor your preferences to see what exciting and rewarding opportunities await in the field of healthcare. By joining Corewell Health, individuals are not just finding a job; they are stepping into a career filled with potential for growth, professional development, and the chance to make a significant impact in the healthcare industry.
Learn more about Corewell Health
Industry
Hospitals & Medical Centers
* Ladders Estimates

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