Manager, Payment Integrity

Manager Of Payment Integrity

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Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

The Manager of Payment Integrity (PI) leads the strategic design, implementation, and execution of programs aimed at improving payment accuracy and enhancing member affordability. This role serves as a key liaison for reimbursement policy and PI initiatives, ensuring alignment between cost-of-care objectives and departmental priorities through structured governance, ideation, and business case development. The Manager oversees program-level performance tracking to ensure measurable impact and continuous improvement. In close collaboration with Health Care and Finance divisions, this role supports enterprise-wide cost-of-care strategies by identifying operational efficiencies, uncovering savings opportunities, and fostering innovative partnerships that expand the reach and effectiveness of PI initiatives.

Essential Responsibilities :

• Leads the development and execution of enterprise-wide Payment Integrity strategies aligned with financial and operational goals.
• Oversees a comprehensive suite of pre- and post-payment programsincluding claims editing, audits, subrogation, readmission reviews, and coordination of benefitswhile continuously refining approaches to address evolving trends such as value-based care, regulatory shifts, and emerging fraud schemes.
• Manages external vendors supporting audits, analytics, and fraud detection. Ensures accountability through robust service-level agreements (SLAs), key performance indicators (KPIs), and contract negotiations. Monitors and reports on recovery rates, audit turnaround times, and dispute resolution outcomes.
• Directs Fraud Waste and Abuse (FWA) detection efforts in collaboration with Special Investigations Unit (SIU) and compliance teams. Leverages predictive analytics and rules engines to identify suspicious billing patterns, ensuring timely investigation, documentation, and resolution.
• Ensures compliance with ICD-10, CPT / HCPCS, DRG, and CMS guidelines to support accurate coding and reimbursement. Serves as a subject matter expert on complex coding issues and documentation standards, providing training and oversight to internal teams and vendors.
• Integrates Payment Integrity efforts with care quality initiatives, targeting avoidable readmissions and preventable complications. Maintains compliance with CMS, Medicaid, ACA, and state-specific regulations. Leads audit responses and represents the organization in national forums such as AHIP, AAPC, HPRI, NHCAA, New York State DFS, DOH, and HPA.
• Champions the adoption of Artificial Intelligence (AI), machine learning, and automation in audit workflows and fraud detection. Pilots emerging technologies and integrates them into core operations. Collaborates with IT and analytics teams to enhance data infrastructure and reporting capabilities.
• Partners across Claims Operations, Finance, Provider Relations, Compliance, IT, and Care Management to embed Payment Integrity throughout the organization. Translates complex technical concepts into actionable insights for diverse stakeholders.
• Responsible for oversight, management, development, implementation, and communication of department programs.
• Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
• Develop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.
• Coordinate business activities by maintaining collaborative partnerships with key departments.
• Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
• Actively participate as a key team member in Manager / Supervisor meetings.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.

Supporting Responsibilities :

Success Profile :

Work Experience : A minimum of 5 years of progressive experience in healthcare operations. Expertise in claims processing, clinical coding, reimbursement strategies, and / or fraud prevention required. Demonstrated success in strategic planning, vendor oversight, and cross-functional collaboration to drive operational excellence and cost containment required.

Education, Certificates, Licenses : Bachelor's degree required. Candidates with an associate's degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of Work Experience will also be considered Preferred area of focus : Healthcare Operations, Statistics, or a related field.

Knowledge : Proven track record of leading operational initiatives from concept through execution, with a focus on provider reimbursement and claims payment integrity. Deep expertise in managed care claims coding, including CPT, ICD, HCPCS, Revenue Codes, and comprehensive understanding of federal and state Medicaid payment regulations. Proficient in Excel and SQL, leveraging data analysis to drive informed business decisions without reliance on technical support.

Competencies : Building Trust

Building a Successful Team

Aligning Performance for Success

Building Partnerships

Customer Focus

Continuous Improvement

Decision Making

Facilitating Change

Leveraging Diversity

Driving for Results

Environment : Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills : Accountable leadership, Collaboration, Data-driven & Analytical, Delegation, Effective communication, Listening (active), Situational Leadership, Strategic Thinking

Our Values :

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business :

Physical Requirements : Stoop and bend. Sit and / or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer : This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.