Senior Manager, Program Integrity (CPC, RHIT or RHIA required)

Job Summary:

The Senior Manager, Program Integrity is responsible to provide leadership and direction to ensure the goals and strategies of the department are successfully achieved.

Essential Functions:

• Implement optimization opportunities for prepay and post pay medical record auditing procedures and processes improvement auditing timeliness and quality outcomes
• Oversee and ensure that supporting business and regulatory processes and documentation exists and kept current
• Track and communicate production issues and escalations to ensure proper follow-up and coordination
• Maintain project plans for all projects in which configuration is involved and ensure proper completion of those plans and escalation where timeframes will be changed
• Lead new product and new vendor implementations to ensure timeliness and quality of new implementations
• Develop and implement ticket controls and ensure that proper communication and approvals are in place prior to system implementation
• Participate in strategic planning and implement action plans
• Oversight and management of team of medical record coding auditors
• Analyze and make a determination of appropriate reimbursements and/or modifications of Coding review guidelines in partnership with medical directors and clinical staff.
• Contribute to new business readiness through comprehensive coding audit requirements
• Review bulletins, newsletters, periodicals and attend workshops to stay abreast of current issues and trends, changes in laws and regulations governing medical record coding and documentation
• Develop and update procedures to maintain standards for correct medical record auditing or coding to minimize the risk of fraud, waste, abuse and error
• Provide expertise in regard to analytic software and coding which requires knowledge of coding/reimbursement/policy
• Provide oversight of documenting code editing solutions, testing and promotion of changes following established departmental change management processes
• Oversee research of analysis of data in relation to code edits and to draw conclusions to resolve issues as it relates to edits, including participation on provider calls
• Consult in predictive analytic modeling refinement to drive lower false positives
• Monitor and manage applicable departmental expenses based on current year’s budget
• Generate and maintain reportable QAI savings for the department and report combined annual savings based on vendor and line of business
• Provide oversight and expertise of reimbursement methodology pertaining to Ambulatory Procedural Coding (APC), Diagnosis Related Groupers (DRG) and Outpatient Prospective Payment System (OPPS) as well as professional claim reimbursement
• Responsible for hiring, coaching, development and performance management of staff
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree or equivalent years of relevant work experience is required
• Minimum of five (5) years of experience in medical policy is required
• Minimum of five (5) years of management experience is required
• Health plan experience is required
• Facets and clinical editing system or equivalent system experience is required
• Healthcare, technology and EDI issues experience is preferred

Competencies, Knowledge and Skills:

• Advanced computer skills and abilities in Facets
• Medical terminology knowledge
• Proficient in Microsoft Suite to include, Word, Excel, and Access
• High level of programming and systems development knowledge
• Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of business partners
• Demonstrated ability to successfully define a portfolio of initiatives including business requirements gathering, definition/prioritization, project scope definition, project staffing requirements, application configuration, testing approach, training, documentation, reporting strategy, and change management process
• Knowledge of regulatory reporting and compliance requirements
• Excellent written and verbal communication skills
• Effective listening and critical thinking skills
• Strong interpersonal skills and high level of professionalism
• Leadership/management skills
• Effective problem-solving skills with attention to detail
• Ability to work independently and within a team
• Ability to develop, prioritize and accomplish goals
• Knowledge of medical claims payment workflow and processing applications
• Strong working knowledge of Medical Record auditing and oversight of large teams