Senior Manager, Payment Integrity & High-Dollar Claims

Highmark Health; New York (NY); On-site; USD 86,000 - 139,000; Full time

Job summary

Highmark Inc. is seeking a leader to oversee the pre-payment high-dollar claims review process. This role coordinates with Utilization Management, Facility Revenue Cycle, Provider Relations and Sales to ensure accuracy and savings across claims payments.

The candidate will identify system defects, generate recoveries, and drive process improvements with Pay Integrity teams, ensuring compliance and efficient operations within the department.

Qualifications

• Bachelor's degree in Business Administration/Management required; substitutions: 6 years of related experience in lieu of a Bachelor's Degree.

Responsibilities

• Lead pre-payment high-dollar claims review process and drive savings for the organization.
• Coordinate with Utilization Management, Facility Revenue Cycle, Provider Relations and Sales to ensure accuracy of claims payments.
• Identify system defects, drive recoveries via auditing and adjustments, and partner with Pay Integrity teams on complex claims issues.
• Provide guidance on process improvements and participate in policy/program development to boost claims payment accuracy.

Skills

Analytical Skills

Change Control

Claims/Benefit Systems

Financial Forecasting/Modeling

Microsoft Excel

Education

Bachelor's Degree in Business Administration/Management

Tools

Microsoft Excel

Job description

Highmark Inc. is seeking a leader to oversee the pre-payment high-dollar claims review process. This role coordinates with Utilization Management, Facility Revenue Cycle, Provider Relations and Sales to ensure accuracy and savings across claims payments.

The candidate will identify system defects, generate recoveries, and drive process improvements with Pay Integrity teams, ensuring compliance and efficient operations within the department.