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Role Description

The Manager of Payment Integrity (PI) leads the strategic design, implementation, and execution of programs aimed at improving payment accuracy and enhancing member affordability. This role serves as a key liaison for reimbursement policy and PI initiatives, ensuring alignment between cost-of-care objectives and departmental priorities through structured governance, ideation, and business case development. The Manager oversees program-level performance tracking to ensure measurable impact and continuous improvement.

• Leads the development and execution of enterprise-wide Payment Integrity strategies aligned with financial and operational goals.
• Oversees a comprehensive suite of pre- and post-payment programs—including claims editing, audits, subrogation, readmission reviews, and coordination of benefits.
• Continuously refines approaches to address evolving trends such as value-based care, regulatory shifts, and emerging fraud schemes.
• Manages external vendors supporting audits, analytics, and fraud detection.
• Ensures accountability through robust service-level agreements (SLAs), key performance indicators (KPIs), and contract negotiations.
• Monitors and reports on recovery rates, audit turnaround times, and dispute resolution outcomes.
• Directs Fraud Waste and Abuse (FWA) detection efforts in collaboration with Special Investigations Unit (SIU) and compliance teams.
• Ensures compliance with ICD-10, CPT/HCPCS, DRG, and CMS guidelines to support accurate coding and reimbursement.
• Integrates Payment Integrity efforts with care quality initiatives, targeting avoidable readmissions and preventable complications.
• Champions the adoption of Artificial Intelligence (AI), machine learning, and automation in audit workflows and fraud detection.
• Partners across Claims Operations, Finance, Provider Relations, Compliance, IT, and Care Management to embed Payment Integrity throughout the organization.
• Responsible for oversight, management, development, implementation, and communication of department programs.
• Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees.
• Develop annual department budgets and monitor spending versus the planned budget throughout the year.
• Coordinate business activities by maintaining collaborative partnerships with key departments.
• Responsible for process improvement and working with other departments to improve interdepartmental processes.
• Actively participate as a key team member in Manager/Supervisor meetings.
• Actively participate in various strategic and internal committees to disseminate information within the organization.

Qualifications

• A minimum of 5 years of progressive experience in healthcare operations.
• Expertise in claims processing, clinical coding, reimbursement strategies, and/or fraud prevention required.
• Demonstrated success in strategic planning, vendor oversight, and cross-functional collaboration to drive operational excellence and cost containment required.
• Bachelor’s degree required; candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience will also be considered.
• Preferred area of focus: Healthcare Operations, Statistics, or a related field.

Requirements

• Proven track record of leading operational initiatives from concept through execution, focusing on provider reimbursement and claims payment integrity.
• Deep expertise in managed care claims coding, including CPT, ICD, HCPCS, Revenue Codes, and comprehensive understanding of federal and state Medicaid payment regulations.
• Proficient in Excel and SQL, leveraging data analysis to drive informed business decisions without reliance on technical support.

Benefits

• Compensation range: $90,052.16 - $157,591.26.
• Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity.

Company Description

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age.

• PacificSource values the diversity of our community, including those we hire and serve.
• We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to.