Payment Integrity Manager

🔥 12 hours ago

🇺🇸 United States – Remote

💵 $73k - $125k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

👻 Ghost score 0%

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Devoted Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2017

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Devoted Health is a healthcare company that offers Medicare Advantage plans designed to provide comprehensive health coverage with added benefits like dental, eyewear, gym memberships, and prescription drugs at competitive rates. The company emphasizes member support and service, ensuring that clients can easily navigate their benefits and access needed healthcare services. Devoted Health is committed to helping customers save money and enhance their health and wellness through a complete package of benefits and support.

📋 Description

• 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

🎯 Requirements

• 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)

🏖️ Benefits

• 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