Payment Integrity Coding Manager

Estimated Hiring Range:

Bonus Target:

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

Essential Responsibilities

Payment Integrity Operations

• Oversee monitoring, analysis, and reporting of claims activity (e.g., trends, outliers, high-cost claims, line-of-business segmentation).

• Manage development and maintenance of tracking mechanisms, dashboards, and documentation related to audits, findings, and overpayment recoveries.

• Ensure accurate invoicing and reconciliation for programs and vendors; oversee processing of recoupments and refunds.

• Identify root causes of overpayments, track trends, and drive corrective actions with accountable owners.

• Define and execute the enterprise payment integrity and coding audit strategy; align program goals with CareOregon’s mission, vision, values, and strategic plan.

• Build business cases and ROI models to expand initiatives, resources, and technology enabling sustainable savings and improved accuracy.

• Establish governance, KPIs, and reporting cadence for program performance, savings, recoveries, and risk mitigation.

Coding Audit & Education

• Lead a portfolio of coding audits (prospective and retrospective), ensuring accurate capture of diagnosis and procedure codes in claims and chart review data.

• Serve as subject matter expert for ICD-10-CM/PCS, CPT/HCPCS, and associated coding conventions; actively maintain and enforce AMA/CMS guidelines.

• Lead Risk Adjustment Data Validation (RADV) and related diagnosis code audits (for Finance/Risk Adjustment as applicable).

• Develop and deliver training and education for providers and internal stakeholders (e.g., recorded modules, reference guides, job aids).

• Create and maintain centralized policy, process, compliance documentation, and SOPs related to coding and risk adjustment.

Quality and User Acceptance Testing

• Manage a team of quality auditors responsible for testing the accuracy of transactional processing.

• Track, trend and report on quality audit results on a weekly, monthly, quarterly and year-to-date basis.

• Develop or expand performance metrics to assess the quality of our payments and their improvement over time.

• Identify and recommend changes/enhancements to processes, processing guides and/or internal tools to achieve improved quality outcomes.

• Develop, manage and schedule Operations user acceptance testing, scripting, playbooks and job aides.

Process Improvement & Analytics

• Work with CareOregon departments to develop and oversee standard operating procedures to ensure that consistent business rules are applied in claim adjudication.

• Review claims, hospital bills, and physician notes and data to devise and refine procedures for identifying billing errors and resolving problematic provider billing practices.

• Work with the Provider Relations team and the Audit and Compliance 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.

• Use data analytics to find new opportunities to expand the scope of payments reviewed.

• Perform variance analysis, assist with medical claims reconciliation and payment process development/improvement.

• Align with fraud waste and abuse reduction initiatives and lead resultant initiatives and projects.

• Develop and maintain department’s policies, procedures and workflows.

• Develop training documents and conduct process trainings on a regular basis.

• Identify opportunities for improvement and recommend solutions.

Employee Supervision

• Manage team and recommend team direction and goals in alignment with the organizational mission, vision, and values.

• Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.

• Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.

• Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.

• Train, supervise, motivate, and coach employees; provide support toward employee development.

• Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.

• Ensure team adheres to department and organizational standards, policies, and procedures.

• Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).

• Perform supervisory tasks in collaboration with Human Resources as needed.

Organizational Responsibilities

• Perform work in alignment with the organization’s mission, vision and values.

• Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.

• Strive to meet annual business goals in support of the organization’s strategic goals.

• Adhere to the organization’s policies, procedures and other relevant compliance needs.

• Perform other duties as needed.

Experience and/or Education

Required

Minimum 5 years’ management experience in health plan claims operations, audit, and/or payment integrity.

Minimum 5 years’ experience as a certified coder and/or Certified Coding auditor with active certification AHIMA or AAPC (e.g., CPC, CCS, CCA, CMC or equivalent).

Preferred

• Experience performing statistical claims analysis in a managed care or health care setting.

  Experience in and/or understanding of payment integrity programs and vendors.

  Experience with SQL Server Reporting, or using business intelligence tools (e.g., Tableau) and data framework.

Knowledge, Skills and Abilities Required

Knowledge

• Strong understanding of state and federal regulations that impact operations in order to properly respond

• Knowledge of how to confidently navigate through complex and challenging business issues

• Working knowledge of different claims coding requirements and payment methodologies (e.g., PPS, Medicare fee schedules, etc.)

• Knowledge of medical terminology

• Knowledge and skill in claims system management, editing software, and coding

Skills and Abilities

• Strong detail-orientation skills

• Strong project management skills

• Adept at prioritizing work

• Ability to develop payment processes and solutions for low income, Medicaid, and Medicare populations

• Comprehensive program development, management and evaluation skills

• Statistical, analytical, problem-solving and organizational skills

• Excellent spoken, written and presentation communication skills

• Ability to use computer programs commonly used for health plan operations

• Ability to lead and influence change and results

• Skill in negotiation and ability to build consensus

• Skill in leading people, including the ability to coach and mentor staff

• Excellent interpersonal skills

• Ability to maintain professional relationships with internal and external staff and departments

• Ability to present a positive and professional image as a leader and representative of CareOregon

• Ability to work well under pressure in a complex and rapidly changing environment

• Ability to support and comply with organizational policies, procedures and guidelines

• Ability to work effectively with diverse individuals and groups

• Ability to learn, focus, understand, and evaluate information and determine appropriate actions

• Ability to accept direction and feedback, as well as tolerate and manage stress

• Ability to see, read, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/day

Working Conditions

Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure

Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment

Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

Work Location: Work from home

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

We are an equal opportunity employer

CareOregon is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.