What are the responsibilities and job description for the Manager, Payment Integrity position at PacificSource Health Plans?
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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
The Manager of Payment Integrity (PI) leads the strategic design, implementation, and execution of programs aimed at improving payment accuracy and enhancing member affordability. This role serves as a key liaison for reimbursement policy and PI initiatives, ensuring alignment between cost-of-care objectives and departmental priorities through structured governance, ideation, and business case development. The Manager oversees program-level performance tracking to ensure measurable impact and continuous improvement. In close collaboration with Health Care and Finance divisions, this role supports enterprise-wide cost-of-care strategies by identifying operational efficiencies, uncovering savings opportunities, and fostering innovative partnerships that expand the reach and effectiveness of PI initiatives.
SUCCESS PROFILE:
Work Experience: A minimum of 5 years of progressive experience in healthcare operations. Expertise in claims processing, clinical coding, reimbursement strategies, and/or fraud prevention required. Demonstrated success in strategic planning, vendor oversight, and cross-functional collaboration to drive operational excellence and cost containment
Education, Certificates, Licenses: Bachelor’s degree required. Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of Work Experience will also be considered Preferred area of focus: Healthcare Operations, Statistics, or a related field.
Knowledge: Proven track record of leading operational initiatives from concept through execution, with a focus on provider reimbursement and claims payment integrity. Deep expertise in managed care claims coding, including CPT, ICD, HCPCS, Revenue Codes, and comprehensive understanding of federal and state Medicaid payment regulations. Proficient in Excel and SQL, leveraging data analysis to drive informed business decisions without reliance on technical support.