Senior Manager, Payment Integrity

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🔥 0 minutes ago

🌵 Arizona, Florida, +15 more states – Remote

🌵 Arizona – Remote 🐊 Florida – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote 🌾 Nebraska – Remote 🌾 North Dakota – Remote 🌪️ Oklahoma – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🏰 Missouri – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote 🧀 Wisconsin – Remote

💵 $88.8k - $133.2k / year

⏰ Full Time

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Medica

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1975

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Medica is a nonprofit health plan and insurer with over 50 years of experience that provides individual & family plans, Medicare, Medicaid, and employer-provided health plans. It offers member services and tools for finding providers, managing benefits and claims, wellness programs, and community-focused initiatives through the Medica Foundation to advance health equity.

📋 Description

• Lead teams responsible for prepayment and post-payment waste/error reviews and primary/secondary editing vendors • Ensure appropriate provider claim payment • Report results, trends, and month-over-month savings to senior leadership • Reverse engineer vendor savings and identify medical cost leakage • Communicate team results and drive improvements in prepayment solutions, recoveries, claims payment accuracy, adjustment volume, provider service, financial liability, and provider billing patterns • Oversee successful implementation of new payment-integrity processes and vendors • Develop, monitor, and report department goals and metrics • Manage coaching, meetings, issue resolution, performance measurement, recruitment, retention, reviews, morale, recognition, and staff development • Establish and maintain department policies, procedures, swim lanes, and vendor processes • Maintain executive reporting and analyze findings and savings monthly, quarterly, and annually • Report overpayments or suspected fraud/abuse to the Special Investigations Unit • Improve processes through automation and efficiency • Oversee savings and recovery efforts and recover overpayments through retrospective data analytics • Uncover root causes, influence stakeholders, sponsor process improvement, and enhance claims-editing solutions • Manage relationships with claims-processing teams and vendors • Maintain knowledge of corporate policies, regulatory codes, legislative directives, and guidelines • Serve as a subject matter expert for internal and external customers • Manage or participate in assigned projects and educate customers on processes, content, and trends • Collaborate with pharmacy operations, payment intent/cost containment, network management, SIU, claims operations, clinical services, operations audit, and internal audit

🎯 Requirements

• Bachelor's degree or equivalent experience in related field • 7+ years of work experience beyond degree • 5+ years of people leadership experience • 4+ years of reimbursement policy experience • Primary home address within a state where Medica is registered as an employer: AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI • Legally authorized to work in the United States at the time of application • Medica does not offer work visa sponsorship for this role

🏖️ Benefits

• Competitive medical, dental, and vision benefits • PTO • Holidays • Paid volunteer time off • 401K contributions • Caregiver services • Incentive plan compensation may be available in addition to base salary