Manager, Payment Integrity Auditing

Workforce Classification:

Telecommuter

Join Our Team: Do Meaningful Work and Improve People’s Lives 

Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

Premera is committed to being a workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development, we’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace.

Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog:  https://healthsource.premera.com/.

As the Manager of Payment Integrity Auditing, you will lead a team of Clinical Coding and Payment Integrity Auditors and oversee the organization's payment integrity audit programs to ensure claims are reimbursed accurately and in compliance with contract provisions, payment policies, coding standards, clinical guidelines, and regulatory requirements. This role is responsible for developing and executing audit strategies across multiple audit types, including DRG validation, itemized bill reviews, level of care reviews, hospital readmission audits, and other post-payment and pre-payment audit initiatives. You will monitor audit performance, oversee internal and vendor audit activities, identify payment and billing trends, and leverage data-driven insights to improve payment accuracy, reduce inappropriate healthcare expenditures, and strengthen the organization's overall payment integrity strategy.

This is a remote/telecommuter position working from home.

What you’ll do:

• Manage a team of clinical coding and payment integrity auditors, ensuring high performance and professional development.

• Direct work products that are primarily related to payment integrity auditing processes and systems and provide recommendations to coordinate and optimize those processes and systems.

• Establish team priorities - determine scope of projects, implementation, analytical work, and responsibilities of team.

• Hire, develop, supervise, and evaluate staff; provide employees with timely feedback and coaching regarding performance at regular intervals and professional development opportunities through work assignments, special projects, further education, and feedback.

• Communicate strategic direction of the payment integrity auditing program, to both staff and other Premera departments.

• Provide guidance on complex payment integrity issues, claim reviews, and ensure timely execution of payment integrity auditing activities.

• Foster a culture of continuous improvement, innovation, and collaboration within the team and across departments.

• Collaborate with leadership to align payment integrity activities with organizational strategies, goals, and compliance requirements.

What you’ll bring:

Required Qualifications

• Bachelor's Degree or (8) years of relevant work experience.

• (5) years of analytical experience in a technical, healthcare, or business-related discipline, including (3) years of experience leading medium to large-size payment integrity projects.

• Certified Professional Coder designation or (6) years of payment integrity experience.

Preferred Qualifications

• (6) years of experience with Premera's health care claims processing system or provider billing and revenue cycle management systems.

• (2) years of experience with hospital bill audits (DRG validation and/or itemized bill review).

• Current Registered Nurse (RN) license.

• Advanced claim auditing, appeals, payment integrity, and data mining experience.

• Experience across all payment integrity disciplines: COB, post-pay data mining and auditing, pre-payment editing and auditing, subrogation, and FWA/SIU.

• Advanced skills in Microsoft Office Suite: Outlook, Word, Excel, PowerPoint.

Knowledge, Skills, and Abilities

• Proven experience building and maintaining positive work relationships with internal staff, external vendors, legal teams, and state and federal agencies.

• Exceptional analytical skills - demonstrated ability to ensure reliability and relevance of data collected.

• Excellent written communication skills - demonstrated ability to compose sensitive, non-routine correspondence requiring tact and diplomacy.

• Excellent speaking and presentation skills - demonstrated ability to deliver presentations regarding controversial issues, ability to deliver talks and speeches before groups and audiences.

• Exceptional problem-solving skills - demonstrated ability to solve a wide range of highly complex, multi-disciplinary problems, which must consider long-term company-wide planning.

Physical Requirements

The following have been identified as essential physical requirements of this job and must be performed with or without an accommodation:

• This is primarily a sedentary role which requires the ability to exert up to 10 lbs. of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body.

• This role requires the ability to use a keyboard and to communicate clearly and understandably in person and over the telephone.

Premera total rewards

Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:

• Medical, vision, and dental coverage with low employee premiums.

• Voluntary benefit offerings, including pet insurance for paw parents.

• Life and disability insurance.

• Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service.

• Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few.

• Generous paid time off to reenergize.

• Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees.

• Employee recognition program to celebrate anniversaries, team accomplishments, and more.

For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.

• Commuter perks make your trip to work less impactful on the environment and your wallet.

• Free convenient on-site parking.

• Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.

• Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.

• Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.

• Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.

Equal employment opportunity/affirmative action:

Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at [email protected] or via phone at 425-918-4785.

Premera is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin.

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.

The salary range for this role is posted below; we generally target up to and around the midpoint of the range.

National Salary Range:

$118,900.00 - $202,100.00

National Plus Salary Range:

$135,600.00 - $230,500.00

*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska.

We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all. We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions.