Senior Manager Payment Integrity

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration - because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm, and every member feels valued.

The Senior Manager, Payment Integrity is responsible for the teams who focus on Prepayment and Post Payment reviews related to waste/error and primary and secondary editing vendors. The primary focus of these team members and vendors are to ensure appropriate provider claim payment. The position will include visibility to senior leadership through reporting of results and trending of findings and savings month over month. This position will be responsible for reverse engineering vendor savings, identifying medical cost leakage, share insight and absorb information that may lead to future findings and/or expansion opportunities. The duties of this position will have oversight and responsibility for communicating team results and working collaboratively to drive improvements through trending of pre-payment solutions, recoveries, the accuracy of claims payment, volume of claims adjustments, impact to provider service, degree of financial liability, and impact to provider billing pattern changes. In addition, this position will be responsible for new payment integrity related implementations are successful. Performs other duties as assigned.

This is a working Manager position and may require the candidate to perform, review or summarize audits and includes training incoming staff on audit practices and procedures.

Key Performance Indicators: 1) Payment Waste and Errors initiative concept innovation 2) Support of Claim Cost Management Initiatives 3) Implementing strategies, with leadership, to achieve Medica's objectives in claims payment accuracy and prevention of Error and Waste overpayments; 4) Working with Director to escalate decision making around payment accuracy and Waste and Error strategy across multiple internal stakeholders; and 5) Executing on corrective action plans related to Errors and Abuse

Key Accountabilities

• Department Management
  
  
  
  • Development, monitoring and reporting of goals and metrics for waste and error reviews and effectiveness
  • Achievement of department production goals
  • General management duties (coaching, team, staff and 1:1 meetings, issue identification, escalation and resolution, performance measurement
  • Department recruitment, selection, retention and performance improvement in coordination with department director
  • Perform annual performance reviews
  • Develop and maintain staff morale and promote teamwork
  • Provide recognition to staff through the reward and recognition programs
  • Coach, encourage and facilitate individual growth and development through specific, timely and consistent feedback
  • Provide technical support to staff by assisting them timely. Guide them to other appropriate resources, if needed. Ensure they receive the training needed to help them be successful in their daily roles as well as provide them opportunities for growth
  • Collaborate with the team to create and maintain department policies, procedures and swim lanes
  • Assure processes are established between Medica, post-pay compliance vendors, the claims processing vendors, and editing system vendors
  • Continue to build and expand into new areas and vendors for payment integrity identification and resolution
  • Oversee and ensure successful implementations of any new payment integrity related processes and/or vendors
  
  
  
  

• Auditing and Reporting
  
  
  
  • Maintain and enhance, as needed, executive reporting package
  • Comprehend Medica's contracting strategy and how it relates to our provider reimbursement and system capabilities
  • Report overpayments or suspected fraudulent and/or abusive behavior to our Special Investigations Unit (SIU)
  • Monitor, manage and report financial impact to management
  • Maintain reporting structure by ensuring consistency to both internal and external customers
  • Improve processes through automation and/or efficiencies in process
  • Review and analyze team findings/savings on a monthly, quarterly and annual basis to identify trends, areas for focus and improvement
  • Assure processes are auditable (able to be reperformed with a paper/electronic trail)
  
  
  
  

• Recovery Oversight & Vendor Management
  
  
  
  • Develop a forecast of potential and error savings goals for analyzing our claims data.
  • Oversee the day-to-day processes used by analysts to perform monthly savings and recovery efforts
  • Recover overpayments identified through retrospective data analytics
  • Uncover root cause of errors, influence stakeholders, sponsor process improvement, and continuously enhance claims editing solutions
  • Develop and maintain good working relationship with Medica's claim processing teams and vendors to drive ongoing payment integrity management to enhance claim processing accuracy and adjustment reduction
  • Maintain up-to-date knowledge of corporate policies, regulatory codes, legislative directive, and other guidelines
  • Set priorities for staff dedicated to following up on payment integrity leads from vendors and internal referrals
  
  
  
  

• Department Representation
  
  
  
  • Be available to internal and external customers as a subject matter expert in the area of waste and errors; and the general processes performed by payment analytics and reimbursement policy.
  • Effectively manage and/or participate in projects as assigned by director
  • Educate and advise customers about the processes, content and trends
  • Assure integration and collaboration with other Medica stakeholders including pharmacy ops, payment intent/cost containment, network management, SIU, claims operations, clinical services, operations audit and internal audit
  
  
  
  

Required Qualifications

• Bachelor's degree or equivalent experience in related field
• 10 years of experience beyond degree

Preferred Qualifications

• Minimum of 5 years leadership experience at a manager or higher level
• Minimum of 5 years of experience in vendor management
• 5+ years of experience with claims recovery systems and tools
• Knowledge of medical coding
• Knowledge and understanding of healthcare products
• Understanding of provider contracting and claims processing
• Understanding of COSMOS, UNET, and HealthRules capabilities preferred
• Process improvement experience preferred
• Presentation skills to a broad audiences including senior and executive leadership
• Intermediate level of proficiency in MS Excel and MS Word

Skills and Abilities

• Train and mentor on technical and operational roles
• Detail oriented/analytical thinking, creative - thinks outside the box
• Strong project management skills and extensive data analysis skills
• Ability to identify trends and clearly articulate them
• Must have strong written and verbal communications skills, meeting facilitation, interpersonal skills, attention to detail, organizational and prioritizing skills

This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, Omaha, NE, or St. Louis, MO.

The full salary grade for this position is $87,100 - $149,300. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $87,100 - $130,620. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.