Payment Integrity Operational Lead

Job Summary

This individual will be responsible for building, scaling, and continuously improving vendor management and provider network functions, supporting various key departments in KPI development and tracking for vendors. The ideal candidate will have a strong understanding of health plans, healthcare provider & vendor contracting, and regulatory requirements. 

Contract Oversight:  look into the intricate details of vendor contracts, this includes compliance to KPI’s SLA’s & adherence to reporting entities Is the report complete and meet the contract Specs. They are responsible for regular oversight, and enforcement of contractual obligations.

Performance Metrics: A leader establishes and monitors performance metrics by working with program sponsors to evaluate vendor performance across all contractual requirements.  After the Contract Oversite Lead assure the reporting is being done by the SOW definition, the Lead will monitor and assure trending information is captured and raise levels of activities when metrics are slipping

Strategic Improvement: The leader requires actively seeking feedback from various departments and vendors to craft and refine strategies to enhance the value derived from vendors. This could include introducing new performance metrics, implementation of new vendors and working with internal departments to align strategies.

Conflict Resolution: Collaboration with program sponsors to assist with disputes to reduce provider abrasion. The leader will also work collaboratively with stake holders to determine root causes and solutions within payment integrity.  

Analytical Prowess: Analyze market trends, contract terms and vendor performances to derive actionable insights.

Essential Functions

• The liaison to assist externally with vendors and internally with other departments.

• Provides troubleshooting and advice on issues as needed.

• Regulatory oversight

• Stay current on regulations and policies.

• Assist the company in ad hoc special projects, including collaborations with external partners, vendor contracting, and other operating model decisions.

• Ensures operational processes and policies are compliant with corporate standards and applicable local, state and federal regulations.

• Continuously seek improvements to processes and systems.

• Communicate confidently to all audiences, including external stakeholders.

• Ensures that the department maintains SLA’s.

• Works on complex issues where analysis of situations or data requires an in-depth evaluation of variable factors.

• Resolution of complex issues.

• Manage and provide third party oversight including vendor governance, auditing oversight and risk management.

• Partnership with stakeholders in preparation for future State and CMS audit readiness

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.

• On-demand pay program powered by Payactiv

• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!

• Optional identity theft protection, home and auto insurance, pet insurance

• Traditional and Roth retirement options with service contribution and match savings

Qualifications

Required

• Excellent communication skills both written and verbal,

• Extensive payment integrity knowledge

• Extensive Medical coding, billing, and auditing experience

• Previous vendor management

• Extensive claims knowledge including reimbursement methodologies and CMS, Medicaid guidelines.

• Excellent interpersonal, negotiation and problem solving/decision making skills.

• Proven leadership and team building skills.

• Strong computer skills including Microsoft Office suite.

• Excellent organizational and multi-tasking skills

• Ability to work under pressure.

• Ability to monitor industry trends.

About Corewell Health

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognize