Payment Integrity Program Manager

Job Summary

As a full-time remote Payment Integrity Program Development Manager, the successful candidate will manage the full lifecycle of edit and audit development, transforming complex coding and billing regulations into actionable logic specifications while utilizing data analytics to ensure accurate claims processing.

Key responsibilities

• Manage the development of payment integrity edits and audits from initial hypothesis to detailed rule design
• Run data queries to validate coding and billing hypotheses and author technical specification documents
• Design defensible payment policies and proactively address provider disputes through strong rule narratives

Required qualifications

• Bachelor's degree and a minimum of 4 years of relevant experience in a health plan or healthcare revenue cycle environment
• Expertise in coding and billing regulations, with familiarity in interpreting CMS policies and NCCI bundling edits
• Proven track record in developing logic rules or guidelines for claims processing
• Strong analytical skills with the ability to read and interpret data query scripts
• Experience in planning and coordinating initiatives to meet payment accuracy goals