Director, Payment Integrity

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

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

Essential Responsibilities

Technical/Operational Leadership

• 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.
  
  

Strategic/Operational Planning

• 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.
  
  

Financial/Resource Management

• 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.
  
  

Relationship Management

• 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.
  
  

Employee Supervision

• 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.
  
  

Required

Experience and/or Education

• 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
  
  

Knowledge, Skills And Abilities Required

Knowledge

• Strong understanding of claims processing, including medical, subrogation, COB processing, and benefits, preferably within a managed health care or health insurance business model
• 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
  
  

Skills And Abilities

• 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 and negotiate favorable outcomes
• Ability to take complex ideas and processes and communicate them in a clear and concise manner
• Familiarity with building and managing internal quality review methods for operations transactions
• Ability to balance strategic and operational priorities, and proactively identify and resolve operational barriers and issues
• Ability to effectively manage, lead and engage internal teams in the fulfillment of roles and responsibilities, as well as strategic partners
• Ability to communicate effectively, both verbally and in writing; strong presentation skills
• Ability to effectively convey business unit goals and plans ensuring integration into strategic plans and initiatives
• Ability to create and develop strategic partnerships with multiple stakeholders both internally and externally
• Leadership competencies in designing, developing and implementing process structure, tools and measurement indicators that drive operational results
• Ability to recognize process deficiencies and recommend and implement improvements
• Ability to think analytically, apply analytical techniques and to provide in-depth analysis and recommendations to senior management using critical thinking and sound judgement
• Ability to operate within a changing environment
• Ability to work effectively with diverse individuals and groups
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/day
  
  

Working Conditions

Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure

Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment and/or mobile technology

Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

Work Location: Work from home

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

We are an equal opportunity employer

CareOregon is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.