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CareOregon · 20 hours ago

Director, Payment Integrity

United States

Full-time

Remote

Senior Level, Lead/Staff

$152K/yr - $186K/yr

10+ years exp

CareOregon is seeking a Director of Payment Integrity to lead the execution of payment integrity strategy across the organization. The role focuses on operational planning, vendor oversight, and ensuring compliance with regulatory requirements, while also managing resources and relationships to achieve strategic goals.

Health Care

Responsibilities

Direct operational payment integrity activities across the organization in support of all lines of business. This includes post and pre-pay audit functions, payment recovery processes, COB, subrogation, medical record review, as well as fraud, waste and abuse clinical reviews

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 to meet corporate and strategic goals; present audit results to include root cause, trend analysis and prepare remediation recommendations on a regularly scheduled basis; monitor remediation activities for effectiveness

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 including standardization and controls design to ensure planned results are delivered

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, including enrollment premium vendors

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

Participate in the development of vision, goals, and strategic plans for Payment Integrity

Develop short- and long-term plans and policies; oversee the development and execution of standard operating procedures

Provide input into the strategic plans of the organization

Maintain a business unit view while establishing department priorities, being cognizant of broader business unit and organizational impacts

Recommend budgets in alignment with short- and long-term plans

Manage resources to ensure priorities are accomplished

Approve resource allocations within budget, including people, finances, and timelines; make decisions on exceptions

Develop comprehensive business case for budget variance requests to include ROI analysis; ensure approval for budget variances as required

Lead effective communication system for work group(s), ensuring a collaborative culture

Build and ensure effective relationships across internal teams and external organizations for current or future integration

Work cross-functionality with internal and external stakeholders in identifying and driving projects, process improvement initiatives, and operational efficiencies

Work closely with senior leadership, peers, and cross-department leadership providing programmatic, organizational, and technical support to ensure effective collaboration and integration of Payment Integrity functions

Represent CareOregon in external meetings and functions, providing productive leadership presence and effectiveness

Lead weekly, monthly and quarterly business review meetings with vendors and executive management as appropriate

Direct team(s) and establish team direction and goals in alignment with the organizational mission, vision, and values

Identify work and staffing models; recruit, hire, and oversee a team to meet work needs, using an equity, diversity, and inclusion lens

Identify department priorities; ensure employees have information and resources to meet job expectations

Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff

Manage, coach, motivate, and guide employees; promote employee development

Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, budgeting, resource allocation, and decision making

Ensure team adheres to department and organizational standards, policies, and procedures

Evaluate employee performance and provide regular feedback to support success; recognize strong performance and addresses performance gaps and accountability (corrective action)

Perform supervisory tasks in collaboration with Human Resources as needed

Qualification

Payment IntegrityHealth OperationsFinancial ManagementData AnalyticsCoding CertificationProject OversightTableauPower BIProcess ImprovementLeadershipCommunicationTeam Management

Required

Minimum 10 years' health operations experience, including a minimum of 4 years' experience in various functions of Payment Integrity, such as claims editing, enrollment, coordination of benefits, overpayment identification, claims auditing, pharmacy, Fraud, Waste and Abuse, and health care subrogation/third party liability

Preferred

Minimum 4 years' experience in a supervisory position

Minimum 8 years' experience in managed care or health insurance industry

Coding certification

Large scale project oversight experience

Financial management experience

Tableau or Power BI experience

Benefits

Medical

Dental

Vision

Life

AD&D

Disability insurance

Health savings account

Flexible spending account(s)

Lifestyle spending account

Employee assistance program

Wellness program

Discounts

Multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)

Strong retirement plan with employer contributions

PTO

Paid State Sick Time

Paid holidays

Volunteer time

Jury duty

Bereavement leave