Director Payment Integrity Capabilities

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

**CANDIDATE MUST BE US Citizen (due to contractual/access requirements)

Hybrid (Pittsburgh/Camp Hill):** For candidates within a 50-mile radius of our Pittsburgh or Camp Hill offices, an in-office presence is required Tuesday through Thursday.

This job develops, implements, and monitors large scale initiatives using internal and external (vendor) technologies and resources to drive additional Payment Integrity savings; manages approximately $600M in vendor savings annually and generates approximately $150M in revenue for Payment Integrity initiatives. Responsible for all aspects of the vendor management process to include contracting, developing KPIs, business and technical implementation, testing, monitoring, and reporting; regularly leads the organizational adoption of new edits/analytics to drive incremental savings. Oversees insourced processes previously performed by vendors including Provider Education, Referenced Based Pricing, and building edit capabilities. Responsible for the Payment Integrity appeal process, leveraging the Independent Review Organizations.

ESSENTIAL RESPONSIBILITIES

• Perform management responsibilities to include, but are not limited to : involved in hiring and terminations decisions, coaching and development, rewards and recognition, performance management and staff productivity, Plan, organize, staff, direct and control the day-to-day operation of the department, develop and implement policies and programs as necessary, may have budgetary responsibility and authority.

• Responsible for Payment Integrity vendor relationships including the procurement process (RFP/RFI), technical and operational implementation, governance, monitoring of metrics (KPIs/SLAs), invoice reconciliation, and achievement of results; facilitate business results review meetings and coordinate across the Enterprise to implement additional savings opportunities.

• Responsible for assessing opportunities, incorporating changes to policy, updating reimbursement policy and system to maximize savings, and implementing change.Ensure advanced communication to key stakeholders both internally and externally.

• Responsible for working with IT on insourcing programs to ensure similar vendor capabilities and savings results/revenue for Highmark; implement, test, and monitor the insourced programs.

• Oversee client invoicing process to ensure Payment Integrity is generating shared savings revenue according to client contractual terms; ensure resolution of billing issues/inquiries.

• Ensure overall saving targets are achieved through defining aggressive financial goals; adjust priorities to ensure resources are properly aligned to effectively achieve annual savings targets.

• Other duties as assigned or requested.

EXPERIENCE

Required

• 7 years of experience in management or leadership role

• 7 years of experience in healthcare industry

• 7 years of experience in engaging, influencing, and advising senior executive leaders

• 7 years of experience working in complex matrixed environment

• 7 years of experience in claims analysis and/or investigations activities (for operation areas)

• 7 years of experience including budget administration, financial forecasting, cost allocation techniques, budget analysis and reporting

• 7 years of experience in review of payments or hospital reimbursements

• 7 years of experience in provider claim review and recoveries

• 7 years of experience in positions requiring the monitoring and measurement of financial impact analyses

Preferred

• None

SKILLS

• Knowledge of the Common Procedure Coding System (HCPCS)

• Comprehension of Highmark reimbursement policies impacting high dollar claims

• Understands and applies appropriate Centers for Medicare and Medicaid (CMS) guidelines to coding

• Excellent verbal and written communication skills

EDUCATION

Required

• Bachelor's degree in business, finance, healthcare, or related field or relevant experience and/or education as determined by the company in lieu of bachelor's degree.

Preferred

• Master's degree in business Administration

LICENSES or CERTIFICATIONS

Required

• None

Preferred

• Certified Professional Coder (CPC)

• Certified Fraud Examiner (CFE)

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office- or Remote-based

Teaches / trains others

Occasionally

Travel from the office to various work sites or from site-to-site

None

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Never

Lifting: up to 10 pounds

Never

Lifting: 10 to 25 pounds

Never

Lifting: 25 to 50 pounds

Never

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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For accommodation requests, please contact HR Services Online at [email protected]

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Req ID: J278151