Job Description
A bit about this role:
As our Senior Payment Integrity Program Development Manager – Operational Excellence, you will help ensure our internal and vendor-supported payment integrity edits and audits are implemented accurately, perform as intended, and continue delivering value over time.You will combine payment integrity expertise, analytical judgment, and operational leadership to manage complex portfolio activities, investigate performance issues, and develop more effective and scalable ways of working. Partnering across technical and operational teams, you will drive improvements that strengthen program accuracy, financial performance, efficiency, and provider experience.Success means not only resolving today's problems, but improving the systems that prevent them from recurring.Your responsibilities and impact will include:
- Portfolio Performance & Optimization: Evaluate the effectiveness of payment integrity edits and audits, independently investigate complex performance or operational issues, identify root causes, and drive improvements in accuracy, financial outcomes, and provider experience.
- Implementation & Validation Assurance: Ensure new and modified payment integrity programs are appropriately validated and implemented as intended. Partner with technical and operational teams to strengthen testing, quality controls, and implementation reliability.
- Portfolio Maintenance & Operational Execution: Lead assigned internal and vendor-supported portfolio activities, ensuring effective prioritization, issue resolution, maintenance, and ongoing program performance.
- Operational Transformation & Scalability: Identify and implement improvements to processes, workflows, and supporting capabilities across validation, monitoring, maintenance, and knowledge sharing. Leverage technology, automation, and operational best practices to improve efficiency, transparency, and scalability.
- Cross-Functional Leadership & Influence: Independently advance complex initiatives, develop evidence-based recommendations, and build alignment across Payment Integrity, Engineering, Data Science, Claims, Compliance, and other stakeholders to achieve measurable results.
Required skills and experience:
- Bachelor's degree and 6+ years of relevant professional experience, including substantial hands-on payment integrity experience within a health plan or payment integrity vendor.
- Strong understanding of healthcare claims, payment integrity edits and audits, claims adjudication, Medicare/CMS reimbursement policies, NCCI/CCI edits, and supporting operational processes.
- Demonstrated ability to investigate complex payment integrity issues, analyze root causes, and drive effective resolution.
- Strong analytical and technical literacy, including the ability to read and interpret SQL queries, claims data, configuration specifications, validation results, and performance metrics.
- Proven experience designing and implementing operational improvements, scalable workflows, or technology-enabled solutions that deliver measurable results.
- Demonstrated ability to independently explore and apply analytical tools, technology, and automation to improve workflows, identify opportunities, and develop scalable operational solutions.
- Experience collaborating with technical and operational partners to implement, troubleshoot, or improve payment integrity programs.
- Demonstrated ability to independently lead complex, multiphase initiatives, exercise sound judgment, and influence cross-functional stakeholders.
Desired skills and experience:
- Experience with Medicare Advantage and Commercial payment integrity programs.
- Experience with vendor-supported claims editing platforms or proprietary payment integrity solutions.
- Professional coding certification (e.g., CPC, CCS) or comparable reimbursement expertise.
- Experience implementing AI-enabled analytics, automated testing, performance monitoring, or workflow automation to improve payment integrity operations.
#LI-Remote
Salary range: $110,500 - $150,000 / year
The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.
Our Total Rewards package includes:
Employer sponsored health, dental and vision plan with low or no premium
Generous paid time off
$100 monthly mobile or internet stipend
Stock options for all employees
Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
Parental leave program
401K program
And more....
*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.
