What are the responsibilities and job description for the Manager – Payment Integrity & Clinical Audit position at SoTalent?
Manager – Payment Integrity & Clinical Audit
A leading healthcare organisation is seeking a Manager – Payment Integrity & Clinical Audit to lead payment integrity initiatives focused on readmission reviews, reimbursement accuracy, cost recovery, and regulatory compliance. This leadership role oversees a team of auditors and clinical professionals responsible for ensuring payment accuracy, improving audit quality, and driving operational excellence across payment integrity programmes.
Key Responsibilities
- Lead payment integrity initiatives focused on potentially preventable readmissions, payment accuracy, cost recovery, and cost avoidance.
- Manage a team of clinical auditors and payment integrity professionals, ensuring high-quality, consistent, and compliant audit outcomes.
- Oversee readmission review programmes, including MS-DRG and APR-DRG validation activities, to support accurate reimbursement decisions.
- Collaborate with cross-functional teams including Finance, Medical Economics, Compliance, Legal, Provider Relations, Technology, and Health Plan operations to develop and enhance payment integrity strategies.
- Monitor programme performance against operational, financial, and quality metrics, identifying trends, risks, and opportunities for improvement.
- Ensure compliance with federal and state regulations, payer requirements, contractual obligations, and internal payment integrity policies.
- Prepare and present audit findings, performance reports, and recommendations to senior leadership and key stakeholders.
- Identify operational gaps and implement process improvements to strengthen audit effectiveness and payment accuracy.
- Develop standardised audit methodologies, review criteria, and best practices across payment integrity programmes.
- Coach, mentor, and develop team members while promoting accountability, collaboration, and continuous improvement.
- Act as a subject matter expert on payment integrity, reimbursement methodologies, coding standards, and readmission review processes.
Requirements
- Bachelor's degree in Healthcare Administration, Business, Public Health, Nursing, Health Information Management, or a related field (equivalent experience may be considered).
- Master's degree preferred.
- Minimum of 5 years' experience in Payment Integrity, including readmission review and DRG validation.
- At least 3 years' experience leading and managing teams.
- Minimum of 2 years' experience using DRG encoder and grouper tools such as 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, Payment Systems Incorporated, or similar platforms.
- Experience with payer claims systems, government healthcare programmes, regulatory compliance, and audit activities is advantageous.
- Project management and vendor management experience is beneficial.
- Experience in inpatient clinical documentation improvement is preferred.
- Active Health Information Management or coding credential (RHIT, RHIA, CCS, CIC, CCDS) required, or Registered Nurse (RN) licensure (or higher clinical qualification) combined with a coding credential.
- Strong leadership, analytical, stakeholder management, and communication skills.
What's Offered
- Competitive salary and comprehensive benefits package.
- Flexible work arrangements.
- Retirement savings and wellness programmes.
- Professional development and tuition assistance.
- Opportunity to lead strategic payment integrity and clinical audit initiatives within a large healthcare organisation.
Industry: Healthcare / Health Insurance / Managed Care / Payment Integrity / Clinical Audit.