Mgr, Payment Integrity

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

Job Summary

Responsible for management of all aspects of the Payment Integrity Program with specific expertise in healthcare payment and reimbursement. The Payment Integrity Manager is responsible for managing staff and associated activities to ensure that saving opportunities are initiated, executed, and reported. These efforts will support the organization’s cost containment efforts specific to medical claims payment and drive payment integrity performance. This position is responsible for coordinating with organizational Executive leadership in setting the priorities, goals and objectives of the Payment Integrity program. Organization strategy will be supported by coordinating with Medical Policy and Provider Relations teams to effectively plan and execute program tactics.

Job Summary

Responsible for management of all aspects of the Payment Integrity Program with specific expertise in healthcare payment and reimbursement. The Payment Integrity Manager is responsible for managing staff and associated activities to ensure that saving opportunities are initiated, executed, and reported. These efforts will support the organization’s cost containment efforts specific to medical claims payment and drive payment integrity performance. This position is responsible for coordinating with organizational Executive leadership in setting the priorities, goals and objectives of the Payment Integrity program. Organization strategy will be supported by coordinating with Medical Policy and Provider Relations teams to effectively plan and execute program tactics.

Essential Functions

• Develops an annual risk assessment and audit plan to support the organization’s Payment Integrity Strategy.
• Develop/sustain and engagement model between the Claims integrity function and other business units within the organization.
• Manages and coordinates substantive audits of medical claims, done internally and externally, for appropriateness of billing and payment, including investigation of inappropriate bundling/unbundling of services, erroneous and duplicate billings, data‑entry omissions and errors, and inappropriate payments. Accurately summarizes and report findings to coordinate Provider communication and recovery of funds.
• Collaborates with Medical, Pharmacy, and Provider teams to determine the best course of action to align policies supporting cost containment activities.
• Establishes process for case assignment to review and respond to Provider appeals.
• Knowledge and understanding of plan products, payment methodologies, medical and payment policies.
• Reviews and provides feedback on provider agreements, member materials, and other internal documents impacted by the Payment Integrity program.
• Interviews, hires and manages staff to best prioritize and coordinate work efforts supporting efficient and effective cost containment activities specifically related to medical claims payments.

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 (i.e., CMS & Medicaid) experience Required
• 5 years of relevant experience An in-depth understanding of provider payment methodologies and concepts (DRGs, capitation, RBRVS payments, APC, percent of charges, etc.) Required
• 5 years of relevant experience Well versed with State and Federal regulations related to healthcare billing and coding Required
• Experience with health care claims Required
• 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
• CRT-Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire preferred Or
• CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire preferred Or
• CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire preferred Or
• CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire preferred Or
• CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire preferred Or
• CRT-Professional Coder, Certified - Payer (CPC-P) - UNKNOWN Unknown Upon Hire preferred Or
• CRT-Professional Coder, Certified - Hospital Outpatient (CPC-H) - UNKNOWN Unknown Upon Hire preferred

Physical Demands

• Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
• Waist to Waist > 5 lbs: Seldom up to 10 lbs
• Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
• Waist to Overhead > 5 lbs: Seldom up to 10 lbs
• Bilateral Carry > 5 lbs: Seldom up to 10 lbs
• Unilateral Carry > 5 lbs: Seldom up to 10 lbs
• Pushing Force > 5 lbs: Seldom up to 10 lbs
• Pulling Force > 5 lbs: Seldom up to 10 lbs
• Sitting: Frequently
• Standing: Occasionally
• Walking: OccasionallyForward Bend - Standing: Seldom
• Forward Bend - Sitting: Occasionally
• Trunk Rotation - Standing: Seldom
• Trunk Rotation - Sitting: Occasionally
• Reach - Above Shoulder: Seldom
• Reach - at Shoulder or Below: Seldom
• Handling: Occasionally
• Forceful Grip > 5 lbs: Seldom
• Forceful Pinch > 2 lbs: Seldom
• Visual Acuity ¹ [None = No; Seldom = Yes]: Seldom

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1239 E Beltline Ave NE - Grand Rapids

Department Name

Payment Integrity Value and Analysis - PH Managed Benefits

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8:00 - 5:00

Days Worked

Monday - Friday

Weekend Frequency

N/A

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on‑site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.