Job Description

• Single or Family Health Insurance with discounted premium rates for wellness program participation.
• 401k with immediate matching (50% on the dollar up to 7% of pay) + additional annual Profit Sharing
• Flexible Paid Time Off Program (29 days off/year)
• Medical and Dependent Care Flex Spending Accounts
• Life insurance, Long Term Disability Coverage, Short Term Disability Coverage, Dental Insurance, etc. 

• Program Leadership and Staff Supervision
  Supervise payment integrity–related staff, including roles supporting clinical documentation, coding, and claims audit functions. Provide coaching, mentoring, performance feedback, and professional development. Oversee daily workflows related to claim audits, risk adjustment validation, large claim reviews, appeals, and recoveries. Establish priorities, assign work, monitor productivity and quality standards, and implement process improvements to enhance efficiency, accuracy, and compliance. Serve as a subject matter resource for payment integrity policies, audit methodologies, and payer‑specific requirements.
• Claims Audit and Payment Validation Activities
  Conduct detailed, line‑by‑line medical and ancillary claim audits using associated medical records, coding guidelines, and provider contracts. Validate medical necessity when applicable, confirm correct coding and reimbursement, and identify overpayments or underpayments. Investigate discrepancies, document findings, and collaborate with internal departments and providers to support corrections, recoveries, and process improvement.
• Large Claim, Risk Adjustment, and Reinsurance Support
  Provide targeted oversight of high‑dollar claims (greater than $50,000), including pre‑ and post‑payment review. Support risk adjustment accuracy through validation of diagnosis coding and documentation. Coordinate with Finance and Claims to support reinsurance identification, documentation, and submission processes.
• Payment Integrity Program Oversight, Appeals, and Provider Collaboration

            Oversee the relationship and performance of payment integrity consultants and vendors, including management of workflows, audit tools, and program policies to ensure accuracy, effectiveness, and annual updates. Lead and support payment integrity–related appeals, including review of cases, development of rationale, and preparation of supporting documentation. Coordinate with internal stakeholders to ensure consistency in determinations and alignment with program goals. Collaborate with Provider Relations and Contracting to support provider communication, education, and issue resolution related to billing practices, documentation, and audit findings.
• Fraud, Waste, and Abuse (FWA) Collaboration
  Identify potential FWA indicators through audit and analytical activities. Collaborate with the Special Investigations Unit (SIU) by referring suspected FWA cases and supporting investigations as requested.
• Reporting, Compliance, and Other Duties
  Prepare summary data and reporting for leadership, including audit outcomes, financial impact, trends, and improvement opportunities. Maintain accurate audit records and ensure adherence to federal, state, and payer‑specific regulations. Complete additional projects and duties as assigned.