Clinical Manager- Payment Integrity

Position Overview:

TheManager of Payment Integrity servesas the bridge between clinicalexpertiseand business operations. This role evaluatespayment integrityprocesses as it relates to carrier reimbursements supports operational decisionmaking ensures quality and compliance and partners with internal and external stakeholders to improve outcomes efficiency and experience. TheManager of Payment Integrity usesclinical knowledge data insights and process thinking to guide program strategy resolve escalations and support continuous improvement across the thisrole leads managesand mentorsthe departments Clinical Analysts.

Responsibilities

• Review medical records for billing accuracy and coding guidelines

• Have experience reviewing both facility and provider claims

• Understand and apply NCCI guidelines and be able to recognize common claims errors

• Review clinical documentation guidelines and cases to ensure accuracy compliance and alignment with standards

• Provide dataanalyticsto support client and carrier requests

• Partner with internal teams to improve accuracyusing data analysis and carrier feedback

• Provide clinicalexpertiseto supportoperational workflowsincluding reviewing claims data medical records

• Partner with crossfunctional teams to design and refine clinical processes that improve outcomes and efficiency

• Monitor clinical quality metrics andidentifytrends gaps and opportunities for improvement

• Prepare carrier responses on open and active referrals

• Lead carrier calls referral calls with carrier network and clients

• Maintainaccuraterecords of clinical policies workflows and quality initiatives

• Lead manage and mentor the departmentsClinicalAnalyst(s)

• Collaborate with IT and serve as the liaison on business and reporting requirements for departmental IT initiatives

• Translate clinical insights into operational recommendations that improve performance cost efficiency and service quality

• Collaborate with Operations Payment Integrity and other teams to resolve escalations

• Support the development of SOPs training materials and process improvements

• Analyze clinical and operational data toidentifypatterns risks and opportunities

• Develop andmaintaindashboards reports and performance summaries for leadership

• Serve as a clinical subjectmatter expert for internal teams carriers partners and vendors

• Provide clear empathetic communication to support escalations case reviews and program updates

• Participate in crossfunctional meetings business reviews and strategic planning sessions

• Develop and deliver training for internal teams on clinical guidelines workflows and quality expectations

• Support onboarding of new team members by providing clinical context and program knowledge

• Ensure teams understand clinical requirements thatimpactoperations payments or partner experience

• Developdata visualizations with Excel ordata visualization tools

Qualifications

• Active clinical license (RN LPN/LVN or other relevant credential) preferredor inactive license with relative clinical experienceor relative clinical data experience

• Bachelors degree in Nursing Healthcare Administration Business or related field; advanced degree a plus

• At least one of the following certifications: CPC CCS or similar clinical/coding credential

• 5 yearsin TPA/Carrier claims processing or payment integrity related areas

• 5 yearsyearsof experience in healthcare administration billing claims processing clinical auditing payment integrity or related areas

• Working knowledge ofmedical claims data medical procedures and healthcare workflows

• Strong attention to detail and ability to communicate clearly in writing and verbally

• Experience working with commercial health plans is a plus

• Solid analytical andcriticalthinkingskills

• Preferred- experience reviewing medical records and/or claims datafrom a payor perspective (preferably in a medical insurance carrier setting)

• Experience working in a crossfunctional business environment strongly preferred

• Experience as a people leader/managing a team

Skills & Competencies

• Strong clinical judgment with the ability to apply guidelines and standards consistently

• Analytical mindset with experience interpreting clinical and operational data

• Excellent communication and relationshipbuilding skills

• Strong organizational and projectmanagement abilities

• Ability to navigate complex issues with professionalism empathy and accountability

• Proficiencywith EMR systems clinical documentation tools or workflow platforms is a plus

Success Indicators

• High accuracy and consistency in clinical reviews and documentation

• Improved quality metrics and reduced clinicalrelated escalations

• Strong crossfunctional alignment between clinical and business teams

• Clear effective communication that supports partners and internal stakeholders

• Scalable clinical processes that support operational growth and efficiency

Who isSmartLightAnalytics

SmartLightAnalytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mindSmartLightworks for self-funded employers to reduce wasteful spending in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.