Lead, Payment Integrity & Claims Savings

Highmark Health; Pennsylvania; Hybrid; USD 86,000 - 139,000; Full time

Job summary

Highmark Inc. seeks a senior leader to manage the pre-payment high dollar claims review, including itemized bill reviews and saving on outlier claims. The role involves regular coordination with Utilization Management, Facility Revenue Cycle Teams, Provider Relations and Sales.

The incumbent drives system improvements, audits, and defect resolution with Highmark Health Solutions to mitigate leakage while ensuring claims payment accuracy.

Qualifications

• Bachelor's degree required; substitutions: 6 years related experience in lieu of degree.
• 5 years in Operational Claims; 3 years in a management/leadership role; 3 years in Process Improvement; 3 years in Medicare; 1 year in Project Management.

Responsibilities

• Carry out management responsibilities including hiring/termination decisions, coaching, rewards, and performance management.
• Plan, organize, staff, direct and control day-to-day department operations; develop policies and programs.
• Explain issues and resolutions to internal and external stakeholders; ensure annual savings targets are met.

Skills

Analytical Skills

Change Control

Claims/Benefit Systems

Financial Forecasting/Modeling

Microsoft Excel

Health Care Operations

Education

Bachelor's Degree in Business Administration/Management

Tools

PMP

CFE

CPC

Job description

Highmark Inc. seeks a senior leader to manage the pre-payment high dollar claims review, including itemized bill reviews and saving on outlier claims. The role involves regular coordination with Utilization Management, Facility Revenue Cycle Teams, Provider Relations and Sales.

The incumbent drives system improvements, audits, and defect resolution with Highmark Health Solutions to mitigate leakage while ensuring claims payment accuracy.