Payment Integrity Program Manager

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $73k - $120k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

📋 Program Manager

🚫👨‍🎓 No degree required

👻 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

• Oversee assigned inpatient Payment Integrity programs, including audit, appeals, quality, and review processes across internal teams, offshore staff augmentation, and external vendors • Ensure audit accuracy, timeliness, coding and clinical quality, regulatory compliance, consistency, and defensibility • Perform complex and escalated inpatient Payment Integrity audits, including clinical validation, DRG coding validation, readmission, and hospital bill audit reviews • Provide clear, defensible audit rationale and determinations • Provide guidance and oversight to internal staff and external vendors through calibration sessions, feedback loops, education, and ongoing quality monitoring • Develop and maintain program-specific training materials, audit guidance, review standards, and supporting documentation • Perform quality reviews and trend analysis of coding, clinical, and audit findings • Monitor program metrics, dispute trends, and vendor results; identify root causes and drive continuous improvement • Collaborate with internal and external stakeholders to resolve complex audit, coding, clinical, and escalation-related issues • Serve as the primary subject matter expert for assigned program areas • Support dispute and appeals management, including escalation review, audit rationale review, and corrective action planning • Support implementation of new audit concepts, review methodologies, and program enhancements

🎯 Requirements

• 2-3 years of experience in healthcare audit, Payment Integrity, coding review, clinical documentation review, or compliance • Strong clinical and inpatient coding knowledge required • CCS, RHIA, RHIT, RN, or equivalent inpatient coding/clinical validation experience required • Demonstrated expertise in inpatient DRG coding and validation strongly preferred • Demonstrated experience with inpatient DRG assignment and validation, including ICD-10-CM coding, principal and secondary diagnosis assignment, MCC/CC identification, POA indicators, inpatient clinical documentation review, severity of illness/risk of mortality concepts, and readmission logic • Demonstrated experience reviewing medical records for audit accuracy, coding/clinical correctness, compliance, and defensibility • Experience operating within structured audit programs, applying defined criteria, documenting rationale, and ensuring consistency and quality of audit outcomes • Ability to interpret clinical and/or coding documentation to support audit decisions and resolve documentation gaps or discrepancies • Experience collaborating across clinical, coding, audit, and operational teams in a complex healthcare environment • Strong analytical skills for assessing audit trends, root causes, and documentation gaps • Strong operational discipline and ability to stay organized amidst varied responsibilities • Proven experience in training payment integrity audits • Bachelor’s Degree desired • Strong leadership, communication, and interpersonal skills • Experience managing offshore vendors • Ability to handle multiple priorities and meet deadlines in a fast-paced environment • Curiosity and hands-on experience with AI tools, automation, or LLM-based workflows in operational settings

🏖️ 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 • Commission eligibility for Sales roles • Parental leave program • 401K program