Post Date: 09/09/2020
Close Date: 10/09/2020
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.