Manager, Claims Operations & Payment Integrity

Portland, TX - USA

Monthly Salary: Not Disclosed

Posted on: 2 days ago

Vacancies: 1 Vacancy

Job Summary

Join Martins Point Health Care - an innovative not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force ofpeople caring for people Martins Point employees are on amission to transform our health care system while creating a healthier community. Martins Point employees enjoy an organizational culture of trust and respect where our values - taking care of ourselves and others continuous learning helping each other and having fun - are brought to life every day. Join us and find out for yourself why Martins Point has been certified as a Great Place to Work since 2015.

Position Summary

The Claims Operations and Payment Integrity Leader is responsible for managing day-to-day operations of Claims Operations and Payment Integrity teams. The leader will be responsible in ensuring claims are processed accurately efficiently and in compliance with all regulatory and Martins Point policies. The role will also focus on preventing overpayments identifying incorrect claims and leading payment integrity recovery efforts in timely manner while improving system controls and implementing automation to improve claims processing efficiency. The leader will partner closely with internal teams and external Payment Integrity vendors to optimize claims and payment integrity outcomes while expanding cost containment capabilities pre and post pay. This position will provide effective leadership to Claims Supervisors and Payment Integrity analysts encompassing hiring leadership coaching counseling communicating mentoring training and creating a positive and cooperative working environment.

Job Description

Key Outcomes:

Ensures claims are adjudicated by maintaining high claims accuracy ensuring regulatory compliance and improving processing efficiency.
Oversees the end-to-end claims adjudication processes and ensure claims are processed within Medicare and Tricare regulatory timeliness.
Monitors claims volumes and productivity metrics and collaborate with Quality Assurance analysist to monitor claim processing accuracy through quality audits and ensure that Supervisors are implementing corrective actions for recurring claim errors and enforcing claims processing workflows/documented processes.
Handles complex or escalated claims issues and collaborate with internal departments for timely resolution.
Ensures and maintains compliance with Medicare Tricare and internal guidelines.
Develops and oversees the organizations payment integrity program aligns with industry standards best practices PI vendors to augment internal expertise and activities.
Leads pre-payment and post-payment audits to identify overpayments duplicate claims and inappropriate billing and coding to ensure recovery efforts are processed timely and accurately.
Utilizes data analytics and reporting tools to identify trends root causes and process improvement opportunities related to claim inaccuracies.
Partners with Provider Relations Finance Compliance and IT teams to improve claims processes enhance automation and ensure accuracy.
Manages relationships with external payment integrity vendors including contract management performance monitoring and validation/reconciliation of results.
Ensures all payment integrity activities comply with Medicare and Tricare regulations payer contracts and internal policies.
Identifies and implements best practices and system enhancements that improve the efficiency accuracy and integrity of payment integrity operations.
Prepares and presents regular reports on all Payment Integrity initiatives/programs (internal and external) outcomes savings and performance metrics to senior leadership.
Establishes monitors and continuously improves processes and supporting policies and ensure PI team complies with all internal policies/procedures.

Education/Experience

Bachelors degree In Finance Business Administration Healthcare Management or related field required.
5 years management and/or leadership experience with a focus on Payment Integrity claims operations healthcare auditing or related roles.
Experience managing industry standard PI vendor partnerships and contract performance

Skills/Knowledge/Competencies (Behaviors):

Knowledge of claims policies and procedures including industry standards from Medicaid CMS and CCI Edits
Understanding of or experience with fraud waste and abuse investigatory techniques and strategies
Solid understanding of standard claims processing systems operations and claims data analysis
Knowledge of HIPAA privacy regulation and rules necessary
Knowledge of CMS reimbursement methodology
ighly developed quantitative and qualitative analytical skills
Strong interpersonal skills including professional communication relationship building and effective written and verbal communication
Proficiency with Microsoft Office Suite applications
Advanced skills in medical terminology CPT/ICD-9/10 coding is preferred
Ability to articulate goals plan and implement processes and meet deadlines

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martins Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process to perform essential job functions and/or to receive other benefits and privileges of employment please contact

Do you have a question about careers at Martins Point Health Care Contact us at:

Required Experience:

Manager