Payment Integrity Manager
CorVel - Fort Worth, TX
posted 16 days ago
About the position
The Policy and Payment Integrity Manager oversees the PPI team and assists with implementation of policies to perform reviews conducted by CERIS including but not limited to itemized bill review, professional review, hospital outpatient and DRG validation. In this position, you will be managing members of the PPI team including developing team strengths and improving weaknesses, identifying team goals, and evaluating team progress. The manager in this role provides trend analysis of internal auditing of claims for claim accuracy related to pre and post payment claims, targeted claims, high dollar claims, and any other claim or record that requires quality review to determine the claim accuracy; assist with development of internal quality assurance measures based on client policy and industry guidelines; perform quality assurance reviews (as needed); assist in researching and implementing best practices related to payment policy, and/or policy initiatives; researching various healthcare policies; interpreting client, state, and CMS payment policies; assist in writing internal quality assurance policies; work with department managers in implementing payment policies and processes to meet quality assurance guidelines. This is a remote position.
Responsibilities
- Assists with development and modification of standard operating procedures for PPI team.
- Utilizes healthcare and auditing experience to design, develop and implement audit criteria that are relevant and necessary for the continuous development services performed by CERIS.
- Exercises good judgment to resolve complex claim and appeal issues and makes sound decisions in the absence of detailed instructions or in an emergency situation.
- Participates in discussion with internal and external stakeholders in regards to reviews conducted by CERIS including but not limited to itemized bill review, professional review, hospital outpatient and DRG validation.
- Research, interpret and apply CMS, Federal, State and client policies to claims review.
- Verbally communicate interpretation of CMS, Federal, State and client policies to providers.
- Demonstrate ability to manage multiple projects, set priorities and manage to committed schedule.
- Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative.
- Works with operational leaders within the business to provide recommendations on opportunities for process improvements.
- Act as a resource and liaison for internal departments, account management, senior management and clients as needed.
- Additional duties as assigned.
Requirements
- Must maintain a current RN licensure in the state of employment.
- Must maintain a current coding license (CPC, CCS, RHIT, etc).
- 3+ years of management experience.
- Minimum of 5 years' experience in Operating Room, either as a circulating RN or scrub RN, as well as 2 years' clinical experience in an acute care facility.
Nice-to-haves
- Previous experience in medical bill coding and auditing.
- Experience in DRG and Clinical Validation.
- Experience in the acute clinical areas of facilities in O.R., I.C.U., C.C.U., E.R., Telemetry, Medical/Surgical, OB or L&D, Geriatrics and Orthopedics.
- Knowledge of worker's compensation claims process.
- Prospective, concurrent and retrospective utilization review.
- Bachelor's degree in healthcare or related field.
- 5+ years of relevant experience or equivalent combination of education and work experience.
- 3+ years hospital bill audit.
Benefits
- Medical (HDHP) w/Pharmacy
- Dental
- Vision
- Long Term Disability
- Health Savings Account
- Flexible Spending Account Options
- Life Insurance
- Accident Insurance
- Critical Illness Insurance
- Pre-paid Legal Insurance
- Parking and Transit FSA accounts
- 401K
- ROTH 401K
- Paid time off
