Program Manager
Core
Manage and oversee the DHP payment integrity program to ensure accurate claims processing, mitigate improper payments, and detect fraud, waste, and abuse.
Role type
Program Manager (Payment Integrity)
Builds
Robust strategies for cost containment and recovery within the health plan's claims ecosystem.
Domain
Healthcare / Managed Care / Insurance
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
Claims data analysis, audit execution, root cause analysis, stakeholder collaboration, regulatory compliance monitoring, dashboard creation, multi-tasking
Preferred skills
Medical coding certification, Medicaid reimbursement methodology expertise, Power BI, SQL, claims configuration experience
Technologies
Excel, Power BI, SQL, CPT, HCPCS, ICD-10, DRG
Responsibilities
Track and analyze claims data to identify trends in provider billing; Execute audits of claims adjudication for compliance; Partner with Special Investigative Unit to report suspicious billing patterns; Manage relationships with external vendors for post-payment reviews; Monitor regulatory bulletins for rate and benefit changes; Maintain dashboards and reports on key performance indicators.
Seniority
Mid-level, hands-on IC
