Mgr, Payment Integrity

Spectrum Health; Grand Rapids (MI); On-site; USD 110,000 - 150,000; Full time

Job summary

Spectrum Health seeks a Payment Integrity Manager to oversee the program with expertise in healthcare payment and reimbursement. You will lead staff, drive savings initiatives, and report outcomes to executive leadership, coordinating with Medical Policy and Provider Relations to plan and execute tactics.

Responsibilities include risk assessment, audits of medical claims, and communicating findings to recover funds while aligning with policies across clinical and administrative teams.

Qualifications

• Bachelor's degree or equivalent in Healthcare, Nursing, or Business with 5 years of relevant experience.
• In-depth understanding of provider payment methodologies (DRGs, capitation, RBRVS, APC, percent of charges).
• Experience with healthcare claim auditing, billing compliance, or revenue cycle.
• Knowledge of state and federal regulations related to healthcare billing and coding.
• Experience with government programs including Medicare/Medicaid preferred.

Responsibilities

• Develops annual risk assessment and audit plan for Payment Integrity Strategy.
• Manage audits of medical claims for appropriate billing and payment; investigate improper bundling/unbundling and duplicate billings.
• Summarize findings and coordinate recovery of funds; report to leadership.
• Collaborate with Medical Policy and Provider Relations to align policies and cost containment tactics.
• Recruit, hire, and manage staff to optimize cost containment in medical claims payments.
• Review provider agreements and materials impacted by the Payment Integrity program.

Skills

Staff management

Auditing

Healthcare reimbursement

Regulatory knowledge

Provider relations coordination

Education

Bachelor's degree in Healthcare/Nursing/Business

5 years of relevant experience

RHIT/RHIA/CCS certifications

CCS-P/CPC-P/CPC-H certifications

Tools

CMS & Medicaid understanding

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.

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

• 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
• CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire preferred
• CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire preferred
• CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire preferred
• CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire preferred
• CRT-Professional Coder, Certified - Payer (CPC-P) - UNKNOWN Unknown Upon Hire preferred
• 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