Manager, Payment Integrity- Readmission
Core
Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy for a national health organization.
Role type
Manager, Payment Integrity (Clinical/Coding)
Builds
Payment accuracy and compliance for potentially preventable readmissions under MS-DRG and APR-DRG methodologies
Domain
Healthcare administration, medical coding, and payment integrity
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
Team leadership, audit oversight, trend analysis, regulatory compliance, MS-DRG/APR-DRG methodology, RHIT/RHIA/CCS/CIC/CCDS credential, Registered Nurse licensure, DRG encoder/grouper tools
Preferred skills
Payer claims systems, government program support, project management, external vendor partnership, inpatient documentation improvement
Technologies
3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, Payment Systems Incorporated
Responsibilities
Lead Payment Integrity initiatives for readmissions and cost recovery; Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams; Monitor program performance against metrics and financial targets; Provide leadership and operational oversight to audit teams; Ensure compliance with federal, state, and managed care requirements; Prepare reports and performance summaries for leadership; Identify process gaps and implement corrective actions; Coach and develop team members; Serve as subject matter expert for Payment Integrity practices
Seniority
Manager, people leadership
