Payment Integrity Manager

🕒 Outubro 9

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $73.000 - $125.000 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

👻 Score fantasma 5%

O que significa: a chance de ninguém estar realmente contratando para esta vaga.Como ler: 60% ou mais significa que achamos que é uma vaga fantasma. Pontuações mais baixas preocupam menos.Por que essa pontuação:

• Aberta há 33 dias.
• As vagas desta empresa costumam ser preenchidas em 23 dias.

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Devoted Health

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 2017

🏥 Saúde

⚕️ Seguro de Saúde

🧘 Bem-estar

Healthcare • Healthcare Insurance • Wellness

A Devoted Health é uma empresa de saúde que oferece planos Medicare Advantage projetados para fornecer cobertura de saúde abrangente com benefícios adicionais como cuidados dentários, óculos, associações a academias e medicamentos prescritos a preços competitivos. A empresa enfatiza o suporte e serviço ao membro, garantindo que os clientes possam navegar facilmente por seus benefícios e acessar os serviços de saúde necessários. A Devoted Health está comprometida em ajudar os clientes a economizar dinheiro e melhorar sua saúde e bem-estar por meio de um pacote completo de benefícios e suporte.

Descrição

• Conduct prepayment and post-payment clinical reviews of inpatient admissions and related readmissions occurring within 30 days of a prior discharge • Review claims and medical records to assess clinical relationships and potential consolidation or preventability of readmissions • Apply organizational policies, regulatory requirements, readmission criteria, and applicable exclusions • Prepare clear, objective, timely, and defensible clinical rationales and supporting documentation • Prepare initial findings, dispute responses, appeal letters, and review additional dispute or appeal documentation • Collaborate with Payment Integrity, appeals, quality, utilization management, and other internal teams on complex or disputed cases • Participate in calibration sessions, peer reviews, quality reviews, and case discussions • Maintain accurate records in clinical review and audit systems while protecting confidential information • Identify trends, documentation concerns, and opportunities to improve readmission review processes and outcomes

🎯 Requisitos

• Registered Nurse degree with a current, active, and unrestricted RN license in at least one U.S. state • Five or more years of experience in clinical nursing, hospital-based care, healthcare audit, Payment Integrity, utilization management, quality review, or a related healthcare environment • Demonstrated experience reviewing inpatient hospital readmissions • Strong knowledge of inpatient clinical care, disease processes, complications of care, discharge planning, and transitions of care • Experience reviewing medical records and synthesizing clinical information from multiple sources • Experience applying established clinical criteria, policies, regulatory guidance, and review methodologies • Strong critical-thinking, analytical, problem-solving, and attention-to-detail skills • Strong written and verbal communication skills • Experience using electronic medical records, claims information, clinical review systems, or audit workflow platforms • Bachelor of Science in Nursing or bachelor’s degree in a related healthcare field (desired) • Experience with Medicare, Medicaid, commercial payer, QIO, State Operations Manual, or payer-specific readmission criteria (desired) • Familiarity with inpatient coding, DRG methodology, clinical validation, or hospital bill audits (desired)

🏖️ Benefícios

• Employer sponsored health, dental and vision plan with low or no premium • Generous paid time off • $100 monthly mobile or internet stipend • Stock options for all employees • Bonus eligibility for all roles excluding Director and above • 401K program • Parental leave program

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