Manager, Payment Integrity Auditing

🔥 12 hours ago

🐻 Alaska, Arizona, +25 more states – Remote

🐻 Alaska – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🌶️ New Mexico – Remote 🌲 North Carolina – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🏰 Missouri – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote ☕ Washington – Remote 🧀 Wisconsin – Remote

💵 $118.9k - $202.1k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Premera Blue Cross

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1945

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Premera Blue Cross is an independent health insurance provider, serving businesses and residents of Washington State and Alaska as a licensee of the Blue Cross Blue Shield Association. The company offers a range of health plans including individual, family, employer-based, and Medicare Supplement plans. However, it has announced that it will exit the Medicare Advantage market as of January 1, 2025. Premera is committed to advancing health equity and community support, evident through its Social Impact Program focused on behavioral health and homelessness solutions in Washington and Alaska. Additionally, Premera complies with federal and state civil rights laws, offering language assistance services to ensure equitable care.

📋 Description

• Lead a team of Clinical Coding and Payment Integrity Auditors. • Oversee payment integrity audit programs to ensure accurate and compliant claim reimbursement. • Develop and execute audit strategies across DRG validation, itemized bill reviews, level of care reviews, hospital readmission audits, and other post-payment and pre-payment initiatives. • Monitor audit performance and oversee internal and vendor audit activities. • Identify payment and billing trends and use data-driven insights to improve payment accuracy and reduce inappropriate healthcare expenditures. • Direct work products related to payment integrity auditing processes and systems. • Establish team priorities, project scopes, implementation activities, analytical work, and responsibilities. • Hire, develop, supervise, and evaluate staff; provide feedback, coaching, and professional development opportunities. • Communicate strategic direction to staff and other Premera departments. • Guide complex payment integrity issues and claim reviews. • Foster continuous improvement, innovation, and collaboration. • Collaborate with leadership to align activities with organizational strategies, goals, and compliance requirements.

🎯 Requirements

• Bachelor's Degree or 8 years of relevant work experience. • 5 years of analytical experience in a technical, healthcare, or business-related discipline. • 3 years of experience leading medium to large-size payment integrity projects. • Certified Professional Coder designation or 6 years of payment integrity experience. • 6 years of experience with Premera's health care claims processing system or provider billing and revenue cycle management systems (preferred). • 2 years of experience with hospital bill audits, including DRG validation and/or itemized bill review (preferred). • Current Registered Nurse (RN) license (preferred). • Advanced claim auditing, appeals, payment integrity, and data mining experience (preferred). • Experience across COB, post-pay data mining and auditing, pre-payment editing and auditing, subrogation, and FWA/SIU (preferred). • Advanced skills in Microsoft Office Suite: Outlook, Word, Excel, PowerPoint. • Experience building and maintaining work relationships with internal staff, external vendors, legal teams, and state and federal agencies. • Exceptional analytical, written communication, speaking, presentation, and problem-solving skills. • Ability to perform the stated physical requirements with or without accommodation.

🏖️ Benefits

• Medical, vision, and dental coverage with low employee premiums. • Voluntary benefit offerings, including pet insurance. • Life and disability insurance. • Retirement programs, including a 401K employer match and a pension plan vested after 3 years of service. • Wellness incentives with mental well-being resources, counseling services, stress management programs, and mindfulness programs. • Generous paid time off. • Tuition assistance for undergraduate and graduate degrees. • Employee recognition program. • Commuter perks. • Free convenient on-site parking. • Subsidized on-campus cafes. • On-site health and wellness activities. • Fitness and well-being center with in-person and virtual workouts and nutritional counseling.