[Hiring] Director, Payment Integrity @CareOregon

Role Description

This position is responsible for leading the execution of payment integrity strategy and activity across the organization. Time is focused on business group and vendor oversight, with secondary time on enterprise-wide engagement. Primary duties include operational planning and oversight, as well as resource, relationship, and people management. This position provides input into strategic plans for the broader organization.

Estimated Hiring Range: $152,415.00 - $186,285.00

Bonus Target: Bonus - SIP Target, 10% Annual

Essential Responsibilities

• Direct operational payment integrity activities across the organization in support of all lines of business.
• Lead the execution of strategic initiatives, plans, and goals in alignment with organizational vision and goals.
• Ensure payment integrity processes are in compliance with Federal and state regulatory and contractual requirements.
• Provide oversight and ensure updated policies and procedures are maintained across Operations.
• Design, implement, and oversee a robust operations and vendor quality review audit program.
• Ensure payment integrity productivity, financial and quality targets are established, measured, and reported.
• Establish business cadence (weekly, monthly, quarterly business reviews) to ensure results are met and/or exceeded.
• Prepare and present on the progress of Payment Integrity capability-building.
• Effectively use business intelligence and data analytics to monitor operations and identify cross functional process improvement opportunities.
• Instill work culture of continuous process improvement, innovation, and quality.
• Oversee the development and implementation of cross-functional operations improvements.
• May serve as a sponsor or chair for key projects and initiatives involving Payment Integrity.
• Oversee Payment Integrity projects and implementation.
• Oversee multiple Payment Integrity vendor relationship(s) and performance.
• Identify cost effective technologies, workflows and sourcing partnerships necessary to meet strategic commitments.
• Develop payment integrity inventory tracking and staff forecasting tools.
• Oversee payment integrity vendor performance, as well as vet new payment integrity vendor offerings/expansions.

Qualifications

• Minimum 10 years’ health operations experience, including a minimum of 4 years’ experience in various functions of Payment Integrity.
• Minimum 4 years’ experience in a supervisory position (preferred).
• Minimum 8 years’ experience in managed care or health insurance industry (preferred).
• Coding certification (preferred).
• Large scale project oversight experience (preferred).
• Financial management experience (preferred).
• Tableau or Power BI experience (preferred).

Knowledge, Skills and Abilities Required

• Strong understanding of claims processing, including medical, subrogation, COB processing, and benefits.
• Understanding of claims fee schedule methodology for healthcare.
• Knowledge of Medical, Behavioral Health, Dental and Pharmacy billing and coding.
• Knowledge of managed care and Medicare health plan concepts, principles, practices, operations and requirements.
• Ability to produce superior results in a financial performance-oriented environment.
• Proficient in developing operations Key Performance Indicator metrics.
• Proficient computer skills, including Microsoft Excel and Word.
• Skilled in budget development and management.
• Strong financial analysis and risk management skills.
• Consensus building skills; ability to influence others without direct authority.
• Ability to communicate complex ideas clearly and concisely.
• Familiarity with building and managing internal quality review methods for operations transactions.
• Ability to balance strategic and operational priorities.
• Ability to effectively manage, lead and engage internal teams.
• Ability to communicate effectively, both verbally and in writing.
• Ability to create and develop strategic partnerships with multiple stakeholders.
• Leadership competencies in designing, developing and implementing process structure.
• Ability to recognize process deficiencies and recommend improvements.
• Ability to think analytically and provide in-depth analysis and recommendations.
• Ability to operate within a changing environment.
• Ability to work effectively with diverse individuals and groups.
• Ability to learn, focus, understand, and evaluate information.
• Ability to accept direction and feedback, as well as manage stress.
• Ability to perform repetitive finger and wrist movement for at least 6 hours/day.

Working Conditions

• Work Environment: Indoor/Office
• Member/Patient Facing: No
• Hazards: May include physical and ergonomic hazards.
• Equipment: General office equipment and/or mobile technology.
• Travel: May include occasional required or optional travel outside of the workplace.
• Work Location: Work from home.

Benefits

• Competitive pay and bonus opportunity.
• Comprehensive benefits package including medical, dental, vision, life, AD&D, and disability insurance.
• Health savings account, flexible spending account(s), lifestyle spending account.
• Employee assistance program and wellness program.
• Strong retirement plan with employer contributions.
• PTO and Paid State Sick Time based on hours worked/scheduled hours.
• Paid holidays, volunteer time, jury duty, bereavement leave, and more.