Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
Position Summary
The Manager of Payment Integrity is responsible for developing, implementing, and managing programs and processes to ensure accurate and appropriate claim payments. This role focuses on preventing overpayments, identifying incorrect claims, and leading recovery efforts while improving system controls and operational efficiency. The manager partners closely with internal teams and external PI vendors to optimize payment integrity outcomes, compliance, regulatory impact, and cost savings.
Job Description
Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.
- Develop and oversee the organization’s payment integrity program aligns with industry standards, best practices, PI vendors to augment internal expertise and activities.
- Lead pre-payment and post-payment audits to identify overpayments, duplicate claims, and inappropriate billing and coding to ensure recovery efforts are processed timely and accurately.
- Utilize data analytics and reporting tools to identify trends, root causes, and process improvement opportunities related to claim inaccuracies.
- Partner with Claims, Provider Relations, Finance, Compliance, and IT teams to improve claims processes, enhance automation, and ensure accuracy.
- Manage relationships with external payment integrity vendors, including contract management, performance monitoring, and validation/reconciliation of results.
- Ensure all payment integrity activities comply with Medicare and Tricare regulations, payer contracts, and internal policies.
- Identify and implement best practices and system enhancements that improve the efficiency, accuracy, and integrity of payment integrity operations.
- Prepare and present regular reports on all Payment Integrity initiatives/programs (internal and external) outcomes, savings, and performance metrics to senior leadership.
- Establishes, monitors, and continuously improves processes and supporting policies and ensure PI team complies with all internal policies/procedures.
Qualifications:
- Bachelor’s degree In Finance, Business Administration, Healthcare Management or related field required
- Professional certification (CPC, COC) required
- 5 years management and/or leadership experience, with a focus on Payment Integrity, claims operations, healthcare auditing, or related roles.
- Experience managing industry standard PI vendor partnerships and contract performance
Knowledge, Skills, Abilities:
- Knowledge of claims policies and procedures, including industry standards from Medicaid, CMS, and CCI Edits
- Understanding of or experience with fraud, waste, and abuse investigatory techniques and strategies
- Solid understanding of standard claims processing systems, operations, and claims data analysis
- Knowledge of HIPAA privacy regulation and rules necessary
- Knowledge of CMS reimbursement methodology
- Highly developed quantitative and qualitative analytical skills
- Strong interpersonal skills, including professional communication, relationship building, and effective written and verbal communication
- Proficiency with Microsoft Office Suite applications
- Advanced skills in medical terminology, CPT/ICD-9/10 coding is preferred
- Ability to articulate goals, plan and implement processes, and meet deadlines
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org