Payment Integrity Coding Manager

🕒 2 dias atrás

🌲 Oregon – Remoto

🌲 Oregon – Remote

💵 $92.070 - $112.530 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

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CareOregon

SiteLinkedInTodas as Vagas

501 - 1000 funcionários

Fundada em 1994

⚕️ Seguro de Saúde

🤝 Sem Fins Lucrativos

Healthcare Insurance • Non-profit

A CareOregon é um plano de saúde focado na comunidade que fornece serviços coordenados de saúde física, comportamental, dental e de apoio social para membros do Oregon Health Plan, atendendo mais de 500. 000 pessoas. A organização opera portais para fornecedores e membros, oferece coordenação de cuidados, telemedicina, serviços de idiomas e tribais, doações comunitárias e alcance, além de programas que abordam os determinantes sociais de saúde, como habitação, nutrição e transporte.

Descrição

• Responsible for developing, implementing, and continuously improving enterprise-wide payment integrity and claims programs and strategies • Overseeing monitoring, analysis, and reporting of claims activity (e.g., trends, outliers, high-cost claims) • Managing development and maintenance of tracking mechanisms, dashboards, and documentation related to audits, findings, and overpayment recoveries • Ensure accurate invoicing and reconciliation for programs and vendors; oversee processing of recoupments and refunds • Identifying root causes of overpayments, track trends, and drive corrective actions with accountable owners • Building business cases and ROI models to expand initiatives, resources, and technology enabling sustainable savings and improved accuracy • Establish governance, KPIs, and reporting cadence for program performance, savings, recoveries, and risk mitigation • Leading a portfolio of coding audits, ensuring accurate capture of diagnosis and procedure codes in claims and chart review data • Developing and delivering training and education for providers and internal stakeholders

🎯 Requisitos

• Minimum 5 years’ management experience in health plan claims operations, audit, and/or payment integrity • Minimum 5 years’ experience as a certified coder and/or Certified Coding auditor with active certification AHIMA or AAPC (e.g., CPC, CCS, CCA, CMC or equivalent) • Preferred experience performing statistical claims analysis in a managed care or health care setting • Experience in and/or understanding of payment integrity programs and vendors • Experience with SQL Server Reporting, or using business intelligence tools (e.g., Tableau) and data framework

🏖️ Benefícios

• medical, dental, vision, life, AD&D, and disability insurance • health savings account • flexible spending account(s) • lifestyle spending account • employee assistance program • wellness program • discounts • multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pet insurance) • retirement plan with employer contributions • PTO and Paid State Sick Time based on hours worked/scheduled hours • paid holidays, volunteer time, jury duty, bereavement leave