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CareOregon Claims Payment Integrity Manager in Portland, Oregon

Position Title: Claims Payment Integrity Manager

Department: Claims

Title of Manager: Executive Director, Health Plan Operations

Supervises: Payment Integrity Staff

Employment Status: Regular - Exempt

Requisition: 14433

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.

Essential Position Functions

Claims Analysis and Standards

  • Individually monitors, analyzes and reports claims information including relevant health care trends and high cost claims by segment.

  • Lead staff in monitoring, analyzing, and reporting on claims activity, including relevant health care trends and high cost claims by segment.

  • Work with Plan departments to develop and oversee standard operating procedures to ensure consistency in business rules applied in claim adjudication.

  • Review claims, hospital bills, and physician notes and data to devise and refine procedures for identifying and resolving billing errors and provider billing practices.

  • Work with the health plan provider team and the auditing team to develop ongoing processes for auditing provider bills, recording errors and tracking collections.

  • Work closely with data analysts, clinical operations, technical, legal and operational teams to create sustainable and scalable cost savings solutions.

  • Performs variance analysis, assists with medical claims reconciliation and payment process development/improvement.

  • Publishes various reports and presentations.

  • Aligns with fraud waste and abuse reduction initiatives and leading resultant initiatives and projects.

  • Interface with various departments, management and individuals external to CareOregon.

  • Communicate findings and improvements with identified work groups, steering committee meetings and external auditors/partners.

  • Expand the scope of payments reviewed by using data analytics to find new opportunities.

  • Develop or expand performance metrics to assess the quality of our payments and their improvement over time.

Management and Leadership

  • Train, supervise and evaluate performance of assigned staff as needed

  • Provide staff with the training, mentoring and resources necessary to carry out their work

  • Ensure adherence to department and organizational standards, policies and procedures

  • Ensure performance goals, expectations and standards are clearly understood by supervised staff

  • Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration

  • Evaluate employees’ performance on an ongoing basis and take appropriate corrective action if needed

  • Perform human resource functions in collaboration with Human Resources

Essential Department and Organizational Functions

  • Propose and implement process improvements

  • Meet deadlines for completion workload

  • Maintain agreed upon work schedule

  • Demonstrate cooperation and teamwork

  • Provide interdepartmental-training on specific job responsibilities

  • Work closely with analysts, clinical operations, technical, legal & operational teams to create sustainable & scalable cost savings solutions

  • Expand the scope of payments reviewed by using data analytics to find new opportunities

  • Meet identified business goals that contribute to departmental goals

Knowledge, skills and abilities required

  • Demonstrated leadership ability to influence change and results

  • Ability to develop payment processes and solutions for low income, Medicaid, and Medicare populations

  • Comprehensive program development, management and evaluation skills

  • Strong understanding of State and Federal regulations that impact operations in order to properly respond

  • Knowledge and skills in claims system management, editing software, and coding

  • Statistical, analytical, problem solving, and organizational skills

  • Demonstrated ability to communicate effectively both verbally and in writing, possessing strong presentation skills

  • Skilled in negotiation and ability to build consensus

  • Excellent interpersonal skills

  • People leadership skills, including the ability to coach and mentor staff

  • Knowledge of how to confidently navigate through complex and challenging business issues

  • Ability to work effectively with a variety of individuals and groups related to the provision of services

  • Ability to use computer programs commonly used for health plan operations

  • Ability to present a positive and professional image

  • Demonstrated ability to maintain professional relationships with internal staff and departments

  • Ability to work well under pressure in a complex and rapidly changing environment

  • Ability to work in an environment with diverse individuals and groups

  • Ability to support and comply with organizational policies, procedures and guidelines

Physical Skills and Abilities

Lifting/Carrying up to 10 Pounds

Pushing/Pulling up to 0 Pounds

Pinching/Retrieving Small Objects

Crouching/Crawling

Reaching

Climbing Stairs

Repetitive Finger/Wrist/Elbow/

Shoulder/Neck Movement

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

Standing

Walking

Sitting

Bending

Seeing

Reading

Hearing

Speaking Clearly

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

Cognitive and Other Skills and Abilities

Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

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

  • Environment: This position’s primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):

☒ Inside/office ☐ Clinics/health facilities ☐ Member homes

☐ Other_____________

  • 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.

  • Equipment: General office equipment

  • Hazards: n/a

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

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