Healthcare Payment Integrity Lead

Priority Health; Grand Rapids (MI); On-site; USD 90,000 - 130,000; Full time

Benefits offered by this job

Health benefits

On‑demand pay

Discounts directory

Retirement options

Identity protection

Job summary

Corewell Health in Grand Rapids seeks a Payment Integrity Manager to lead the program and drive cost containment for medical claims payments. You will manage staff, coordinate audits, and partner with Medical Policy and Provider Relations to execute program tactics.

The role requires extensive healthcare claims experience, deep knowledge of payer methodologies, and strong regulatory expertise, with a focus on achieving savings and program effectiveness.

Qualifications

• Required Bachelor's Degree or equivalent Healthcare, Nursing, or Business
• 5 years of relevant experience Healthcare claim auditing or equivalent combination of auditing, medical coding, healthcare revenue cycle, or regulatory experience
• 5 years of relevant experience An in-depth understanding of provider payment methodologies and concepts (DRGs, capitation, RBRVS payments, APC, percent of charges, etc.)
• 5 years of relevant experience Well versed with State and Federal regulations related to healthcare billing and coding
• Experience with health care claims
• Direct experience in hospital or physician billing, or equivalent experience with a managed care payer Preferred
• Experience working with government programs including Medicare, Medicaid and FEHB Preferred
• RHIT/RHIA/CCS/CCS-P/CPC-P/CPC-H certifications Upon Hire preferred

Responsibilities

• Develops and executes the annual risk assessment and audit plan for Payment Integrity
• Fosters collaboration between Claims integrity and other business units
• Directs audits of medical claims for billing appropriateness and recovery of funds
• Coordinates with Medical, Pharmacy, and Provider teams to align cost-containment policies
• Manages case assignment processes for provider appeals
• Reviews provider agreements and member materials impacting Payment Integrity
• Leads staffing to optimize cost containment in medical claims payments

Skills

Staff management

Healthcare claims

Regulatory knowledge

Payment methodologies

Auditing

Education

Bachelor's degree in Healthcare, Nursing, or Business

Job description

Corewell Health in Grand Rapids seeks a Payment Integrity Manager to lead the program and drive cost containment for medical claims payments. You will manage staff, coordinate audits, and partner with Medical Policy and Provider Relations to execute program tactics.

The role requires extensive healthcare claims experience, deep knowledge of payer methodologies, and strong regulatory expertise, with a focus on achieving savings and program effectiveness.