Payment Integrity Program Manager
The Payment Integrity Program Manager is responsible for the management and oversight of the DHP payment integrity program. This role ensures accurate claims processing in compliance with contracts and state and federal regulations, identifies and mitigates improper payments, identifies trends of potential fraud, waste, and abuse with referral for further investigation, and implements robust strategies for cost containment and recovery. The Program Manager leads the health plan's efforts in the detection, investigation, and resolution of payment discrepancies, collaborating cross-functionally with internal departments and external partners to support organizational goals, regulatory compliance, and financial performance.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or hospital administration as required.
- Maintains utmost level of confidentiality at all times.
- Adheres to health plan policies and procedures.
- Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
- Tracks and analyzes claims data to identify trends in provider billing and the core claims system adjudication to ensure the health plan reimburses only valid, covered services.
- Executes audits of claims adjudication to ensure compliance with the Uniform Managed Care Contract (UMCC), the Uniform Managed Care Manual (UMCM), the Texas Medicaid Provider Procedures Manual, DHP Provider Contracts, and the DHP Provider Manual.
- Partners with the DHP Special Investigative Unit (SIU) to report suspicious provider billing patterns for further investigation.
- Collaborates with internal partners, such as the claims, contracting, finance and configuration teams, to ensure provider contract rates, fee schedules and rate changes are configured appropriately in the core claims system.
- Manages the relationship with external vendors performing post-payment review of the appropriateness of hospital APR DRG code submission.
- Performs root cause analysis of provider refund submissions to identify process improvement opportunities for avoidance of future claim overpayments.
- Monitors the resolution of provider submitted complaints to identify opportunities for improvement in claim accuracy.
- Identifies opportunities for pre or post payment reviews to ensure appropriate reimbursement.
- Maintains dashboards and reports key performance indicators to monitor effectiveness of payment integrity program.
- Monitors Texas Medicaid and Health Partnership (TMHP) and HHSC Bulletins and Notices to identify rate, benefit and administrative changes for implementation, as related to claims adjudication and reimbursement.
- Communicates effectively and professionally both in writing and orally with internal DHP staff, providers, and external partners.
- Demonstrated ability to multi-task and manage multiple priorities.
Associates degree (A. A.) from a two-year college or technical school in Healthcare Administration, Business, Finance or a related field; three to five years related experience in health plan payer operations, managed care, or health plan reimbursement; or equivalent combination of education and experience.
Strong working knowledge of managed care medical coding systems (CPT, HCPCS, ICD-10, DRG); prefer coding certification. Two years or more experience with Medicaid reimbursement methodologies, NCCI edits, Medicaid billing guidelines and state Medicaid payment rules; experience with Texas Medicaid Managed Care is preferred. Experience owning operational projects from concept to execution, especially in the areas of provider reimbursement and/or claims payment integrity. Demonstrated ability to work independently and apply business judgement in a high regulated, cross-functional environment. Advanced proficiency in Excel. Experience with Power BI or SQL is preferred. Two years or more of claims or configuration experience is preferred.
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