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Director, Payment Integrity, Claims Payment Integrity Manager, Portland, OR


Organization: CareOregon
Category: Senior Leadership
Location: Portland, OR
Date Job Posted: October 6, 2020
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Director, Payment Integrity

General Statement of Duties

This position is responsible for leading the execution of payment integrity strategy and activity across the organization. Time is focused on business group and vendor oversight, with secondary time on enterprise-wide engagement. Primary duties include operational planning and oversight, as well as resource, relationship, and people management. This position provides input into strategic plans for the broader organization.

Claims Payment Integrity Manager

General Statement of Duties

The Claims Payment Integrity Manager is responsible for guiding the development and implementation of programs and strategies to ensure the Plan’s corporate claims editing and payment policies meet the strategic goals of the plan. Oversight is enterprise-wide, spanning all CareOregon regions and lines of business. The position requires effective alignment and integration with multiple internal teams, including Legal, Audit, Compliance, Finance, Data Analytics and Network. This position facilitates a coordinated plan of action across internal and external stakeholders.

This position also ensures downstream provider payment appeal activities consistently adhere to corporate policies. This position is responsible for developing and growing the Claims Payment Integrity initiative by developing strong business case scenarios that justify team expansion and growth. He/she will understand the compliance requirements posed by our relationship with the State and CMS regulatory agencies and help ensure regulatory requirements are met.

Education, Experience Certifications

Director, Payment Integrity

Education and/or Experience

Required:

  • Minimum 10 years’ health operations experience, including a minimum of 8 years of progressively responsible experience in various functions of Payment Integrity, such as claims editing, enrollment, coordination of benefits, overpayment identification, claims auditing, pharmacy, Fraud, Waste and Abuse, and health care subrogation / third party liability
  • Minimum 3 years’ experience managing people leaders in a payment integrity or operations capacity

Preferred:

  • Minimum 8 years’ experience in managed care or health insurance industry
  • Large scale project oversight experience
  • Financial management experience
  • Experience with Tableau or Power BI

Claims Payment Integrity Manager

Education and/or Experience

Required:

  • Minimum 5 years’ claims administration experience, including clinical coding

Preferred:

  • Experience performing statistical claims analysis in a managed care/health care setting
  • Clinical coding certification; examples include but are not limited to Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Coder (CMC) or Certified Coding Associate (CCA)
  • Minimum 2 years management experience, including developing and implementing processes and influencing others
  • Associate’s or Bachelor's Degree in Business, Statistics, Healthcare Administration, or related field

Working Conditions

  • Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.

To apply visit: https://www.careoregon.org/careers


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