Director, Payment Integrity

The Director of Payment Integrity will lead efforts in claims cost management identification and implementation of cross functional opportunities resulting in operational efficiency, claim payment accuracy and adherence to industry standard practices. Initiatives will be delivered via internal operational processes and performance management as well with the use of external vendors.

This leadership position is accountable for cost containment strategy development and execution via payment integrity business processes (e.g., reimbursement policy development/maintenance, high dollar audits, health care error/waste/abuse detection and intervention, and implementation and management of claims editing and pricing software) to achieve $50MM+ in annual medical expense savings; plays a lead role on the company's Affordability Committee in relation to Policy & Configuration; recruits and manages insourced and outsourced talent.

The most critical skills and experience required for this role involve: a) designing and implementing a strategic capability development roadmap (new process, technology, people capabilities) for the departments and functions discussed above, while b) simultaneously optimizing near-term operational performance (within fixed process, technology, people constraints) to ensure key performance indicators (KPIs) and appropriate regulatory/compliance standards are met. Performs other duties assigned.

Key Accountabilities

• Strategic Capability Development
  
  
  
  • Develops Payment Integrity future functional strategies and capability roadmaps; identifies how these functions must change/evolve to support Medica 2022-2024 Strategic Plan, mostly notably around two requirements: a) Operational Service Excellence, and b) Ability to Scale/Cost Efficiency. Directs and incorporates industry benchmarks is building these strategies/roadmaps, effectively networking with industry counterparts or vendors to obtain external information needed to shape these strategies and ensure external market/competitive environment is appropriately taken into account. Maintains three-year future state services strategy, encompassing necessary Business Process, Technology Use, and People evolution that will achieve the expected new Key Performance Indicators/KPIs outlined in the 3 Year Operations Plan. Beyond identifying capability improvements, must also establish priorities for the multi-year work/related individual projects. This work will require business case development for each service transformation/improvement
  • Once the strategy/business cases are developed, maps each service strategy/business case to any potential existing or planned Medica program that might serve as a dependency or catalyst for the progression of strategic work. Thus, must be able to effectively identify and negotiate where inter-dependency exists, and how to navigate a) shared scope/funding, or b) separate funding but integrated scope circumstances
  • Leads and/or supports related (Six Sigma/LEAN) process engineering efforts that are either stand-alone or integrated with technology projects/enhancements. Employs quantitative analysis methodology to perform data, cost and benefit, and/or process measurement analysis
  • Develops and manages change management discipline and associated processes with leaders/staff throughout the organization; ensures appropriate communication protocols are used throughout the strategy, planning and implementation lifecycle
  
  
  
  
• Operations Performance Management
  
  
  
  • Directs and oversees payment integrity business process, staff and annual savings targets across all market segments and product lines. Accountable for the speed/TAT, accuracy, and work quality of these automated, semi-automated, and manual workflows, including compliance with CMS and other/state regulatory requirements
  • Oversees development of staffing plans, ensuring all inputs can be secured, and that all output achieve appropriate quality/confidence levels (that can withstand peer review with Corporate Finance)
  • Develops new/revised metrics/KPIs (key performance indicators) on annual basis that reflect new or changing business needs and final dashboard production. Metrics may reflect needed service/accuracy performance levels necessary by regulatory or accreditation bodies (e.g., CMS, NCQA)
  • Effectively leads and champions "performance controls". Monitors metrics performance, and when insufficient, develops formal service recovery plans (aka "glidepaths") that outline root cause, interventions, and expected time duration to recover expected service levels
  • Selects and manages key vendor partners that provide services to Medica's members, providers, employer group customers. This role manages vendor partners for payment integrity services
  • Ensures functional interests are reflected and prioritized in IT Demand management process, such that daily operations' capability can be appropriately maintained or improved
  
  
  
  

Required Qualifications

• Bachelor's degree or equivalent experience, plus 8+ years of experience in the Healthcare setting. 5+ years of leadership in Operations roles
• At least 10 years' experience in the areas of medical claims payment cost containment or payment integrity

Preferred Qualifications

• Clinical and/or healthcare claims operational experience strongly preferred
• Knowledge of claims payment standards and regulations
• Strong communication skills
• Strong experience creating, presenting and reporting outcomes to executive leadership
• Experience with IT capability development to drive and enable operational and vendor solutions
• Demonstrated ability to develop and implement new strategies and encourage others to do the same
• Understanding of how to set, measure and adjustment organization metrics/key performance indicators
• Experience identifying, evaluating, implementing, and overseeing vendor solutions
• Demonstrated experience and skills in developing multi-year Health Plan Operations' strategies and staged capability development plans as a leader of an Operations' functional area or as an industry consultant
• Large project and/or program management experience, inclusive of process/workflow design skills and design/execution of business process controls
• Working in a matrixed organizational or governance environment; ability to influence individuals at all levels of leadership
• Ability to provide work direction and coaching to individuals not under direct authority
  
  
  

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, Omaha NE, or Madison WI.

The full salary range for this position is $111,200 - $190,600. 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.