SENIOR PROJECT MANAGER, CLAIMS PAYMENT INTEGRITY

JOB PURPOSE:

The Senior Project Manager, Claims Payment Integrity supports the Senior Vice President and the Director in the day-to-day operations of the Claims Operations Department. The position performs and delivers accurate and timely claims payment integrity analysis as well as assists in the management of staff and vendor oversight to ensure compliance with federal and state guidelines and meets health plan regulatory and provider contract requirements as well as company objectives. This position requires working knowledge of health care policy and payment methodologies along with strong organizational and analytical skills.

JOB RESPONSIBILITIES:

• Manage, in collaboration with the Director, functions related to claim processing, including monitoring of pending claims, appeals, recoupments, pricing, auditing, and reporting.

• Provide project management support in data collection and tracking in report building to meet the needs of the department and organization.

• Perform accurate and timely data analytics to assess claims payment integrity, including root cause analysis, reconciliation to provider contracts/agreements and Medicare fee schedule.

• Develop analytics of payment trends that will provide accurate and actionable insights for configuration and edit changes. This includes but is not limited to DRG, APC, FFS, capitation, and VBP.

• Coordinate with Finance regarding check runs and provider payments, including refunds, overpayments, and underpayments. Review for potential issues, investigate and propose solutions to leadership.

• Conduct internal audits of department performance and external audits of vendor performance.

• Work with Finance, Compliance, Provider Relations, Care Delivery, and Business Development to ensure accurate claim outcomes and accurate and actionable insight for key decision-makers.

• Assist in the collection and preparation of data for applicable state, federal, and internal inquiries.

• Maintain organization of workflows related to TPA and internal operations impacting claim adjudication.

• Support staff in the management of appeals, provider projects, and ad hoc projects.

• Ensure a high level of customer service for internal and external customers.

• Review current business processes and recommend modifications to streamline workflow.

• Review/develop responsible areas policies and procedures as needed.

• Prepare ad-hoc financial modeling, analysis, and projections.

• Work on special projects as assigned.

Schedule: 8:30AM – 5:30PM

Weekly Hours: 40

QUALIFICATIONS:

Education: BA/BS in Business, Health Administration, or other quantitative discipline.

Experience:

• Minimum of five (5+) years of data analytics in a managed care setting is required.

• Minimum of three (3+) years of people manager/supervisory experience is strongly preferred.

• Experience with project management.

• Industry level knowledge of Medicaid and Medicare rules, regulations, and processes.

• Must have advanced Excel, Access, Visio and PowerPoint skills.

• Industry level knowledge of CPT, ICD9/ICD10, HCPCS, RBRVS, and revenue coding.

• Working knowledge of contract interpretation and contract management.

• Knowledge and understanding of claims modifiers and their impact on payment.

• Knowledge and understanding of 1500s, 1450s, and 837s.

• Good working knowledge of health maintenance organizations and medical terminology.

• Excellent verbal and written communication skills and the ability to effectively collaborate with other departments in the successful resolution.

• Highly organized with an attention to details.

• The ability to adapt to and lead change in a business environment is also critical.

• Must be an independent and creative thinker.

• Experience working effectively and influencing others on cross-functional teams.

• Must be able to manage and deal with conflict and stressful situations in a calm, reasonable and composed manner.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

• Standing – Duration of up to 6 hours a day.

• Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.

• Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA g