Senior Manager, Payment Integrity Program Development

Devoted Health Services; United States; Vor Ort; USD 150.000 - 210.000; Vollzeit

Zusammenfassung

Devoted Health Services is seeking a senior leader to steer the Payment Integrity Program Development portfolio. The role combines claims expertise, analytics, and cross-functional leadership to optimize edits, audits, and provider outcomes.

You will drive complex, multi-phase initiatives with independent judgment and a focus on scalable processes. You will collaborate with clinical, coding, and engineering partners to translate concepts into concrete requirements, monitor performance, ensure

Qualifikationen

• Bachelor's degree and a minimum of 6 years of relevant professional experience in a health plan, payment integrity vendor, healthcare revenue cycle environment, or related healthcare setting.
• Strong expertise in healthcare claims, payment integrity, claims editing, reimbursement, or related healthcare payment operations.
• Demonstrated experience implementing, validating, maintaining, or optimizing payment integrity edits, audits, claims logic, or comparable healthcare operational programs.
• Demonstrated ability to independently investigate complex claims or operational issues, perform root cause analysis, and translate findings into actionable solutions.
• Strong analytical literacy, including the ability to interpret claims data, operational metrics, technical findings, and performance trends.
• Demonstrated ability to lead complex, multi-phase initiatives across multiple functions with limited oversight.
• Strong independent judgment and ability to develop recommendations where data, policy, or operational signals may be incomplete or ambiguous.
• Strong communication, prioritization, and influencing skills, including the ability to align cross-functional partners and drive work through resolution.

Aufgaben

• Program Operations & Portfolio Management: Manage assigned internal and vendor-supported payment integrity programs across implementation, monitoring, maintenance, and ongoing operational support. Establish priorities, coordinate resources, and ensure effective execution.
• Portfolio Assurance & Optimization: Evaluate program performance, including savings, hit rates, yield, turnaround times, and provider impacts. Identify trends, emerging risks, and opportunities for improvement.
• Complex Root Cause Analysis & Remediation: Independently investigate complex claims, configuration, and operational issues. Determine root causes and impact, develop evidence-based recommendations, and drive resolution across functions.
• Concept Implementation & Validation: Partner with clinical, coding, and reimbursement SMEs to translate concept logic into clear implementation requirements. Collaborate with Engineering, Product, Data Science, and operational teams to support configuration, testing, deployment, and troubleshooting.
• Maintenance, Monitoring & Compliance: Coordinate portfolio maintenance, backsweeps, performance monitoring, regulatory updates, and compliance-related activities. Ensure appropriate controls, documentation, escalation, and follow-through.
• Program & Process Improvement: Identify recurring inefficiencies, capacity constraints, and operational risks. Partner with department leadership to evaluate and implement improvements involving workflows, resource allocation, automation, and technology.
• Data-Driven Decision-Making: Use claims information, operational metrics, analytical tools, and performance trends to investigate issues, evaluate opportunities, and inform recommendations.
• Cross-Functional Leadership & Influence: Develop a clear point of view, constructively challenge assumptions, and bring together stakeholders across Payment Integrity, Claims, Compliance, Engineering, Product, and Data Science to achieve measurable outcomes.
• Project Management & Operational Scalability: Independently lead complex, multi-phase initiatives, manage competing priorities and dependencies, and strengthen repeatable processes, knowledge sharing, and cross-coverage.

Kenntnisse

Payment integrity

Claims analysis

Root cause analysis

Cross-functional leadership

Data interpretation

Project management

Communication

Ausbildung

Bachelor's degree

Jobbeschreibung

Devoted Health Services is seeking a senior leader to steer the Payment Integrity Program Development portfolio. The role combines claims expertise, analytics, and cross-functional leadership to optimize edits, audits, and provider outcomes.

You will drive complex, multi-phase initiatives with independent judgment and a focus on scalable processes. You will collaborate with clinical, coding, and engineering partners to translate concepts into concrete requirements, monitor performance, ensure