Job Summary:

The Senior Manager, Program Integrity is responsible to provide leadership and direction to ensure the goals and strategies of the department are successfully achieved.

Essential Functions:

• Implement optimization opportunities for prepay and post pay medical record auditing procedures and processes improvement auditing timeliness and quality outcomes
• Oversee and ensure that supporting business and regulatory processes and documentation exists and kept current
• Track and communicate production issues and escalations to ensure proper follow-up and coordination
• Maintain project plans for all projects in which configuration is involved and ensure proper completion of those plans and escalation where timeframes will be changed
• Lead new product and new vendor implementations to ensure timeliness and quality of new implementations
• Develop and implement ticket controls and ensure that proper communication and approvals are in place prior to system implementation
• Participate in strategic planning and implement action plans
• Oversight and management of team of medical record coding auditors
• Analyze and make a determination of appropriate reimbursements and/or modifications of Coding review guidelines in partnership with medical directors and clinical staff.
• Contribute to new business readiness through comprehensive coding audit requirements
• Review bulletins, newsletters, periodicals and attend workshops to stay abreast of current issues and trends, changes in laws and regulations governing medical record coding and documentation
• Develop and update procedures to maintain standards for correct medical record auditing or coding to minimize the risk of fraud, waste, abuse and error
• Provide expertise in regard to analytic software and coding which requires knowledge of coding/reimbursement/policy
• Provide oversight of documenting code editing solutions, testing and promotion of changes following established departmental change management processes
• Oversee research of analysis of data in relation to code edits and to draw conclusions to resolve issues as it relates to edits, including participation on provider calls
• Consult in predictive analytic modeling refinement to drive lower false positives
• Monitor and manage applicable departmental expenses based on current year’s budget
• Generate and maintain reportable QAI savings for the department and report combined annual savings based on vendor and line of business
• Provide oversight and expertise of reimbursement methodology pertaining to Ambulatory Procedural Coding (APC), Diagnosis Related Groupers (DRG) and Outpatient Prospective Payment System (OPPS) as well as professional claim reimbursement
• Responsible for hiring, coaching, development and performance management of staff
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree or equivalent years of relevant work experience is required
• Minimum of five (5) years of experience in medical policy is required
• Minimum of five (5) years of management experience is required
• Health plan experience is required
• Facets and clinical editing system or equivalent system experience is required
• Healthcare, technology and EDI issues experience is preferred

Competencies, Knowledge and Skills:

• Advanced computer skills and abilities in Facets
• Medical terminology knowledge
• Proficient in Microsoft Suite to include, Word, Excel, and Access
• High level of programming and systems development knowledge
• Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of business partners
• Demonstrated ability to successfully define a portfolio of initiatives including business requirements gathering, definition/prioritization, project scope definition, project staffing requirements, application configuration, testing approach, training, documentation, reporting strategy, and change management process
• Knowledge of regulatory reporting and compliance requirements
• Excellent written and verbal communication skills
• Effective listening and critical thinking skills
• Strong interpersonal skills and high level of professionalism
• Leadership/management skills
• Effective problem-solving skills with attention to detail
• Ability to work independently and within a team
• Ability to develop, prioritize and accomplish goals
• Knowledge of medical claims payment workflow and processing applications
• Strong working knowledge of Medical Record auditing and oversight of large teams

Licensure and Certification:

• Certified Medical Coder (CPC, RHIT or RHIA) is required
• Active, unrestricted Registered Nurse (RN) license is preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.