Manager Integrity

Highmark Inc.

This job is responsible for the overall pre-payment high dollar claims review process for Highmark including the review of itemized bills for saving on outlier claims. This requires interaction and regular coordination with Utilization Management, Facility Revenue Cycle Teams, Provider Relations and Sales. Every claim paying over a certain amount is reviewed by this team utilizing multiple lenses including processor quality and the assignment of errors to individual claims processors as well as claims payment accuracy.

The incumbent also represents Highmark at the Association level with regards to the High Dollar Claims process across the Blues, providing feedback and influencing change when necessary. Additionally, the incumbent is responsible for identifying system issues/defects primarily from a claim processing perspective and generating recoveries via auditing and claims adjustments. These savings are apart of C2V under the Claims Leakage team.

The incumbent works with various internal parties, as well as Highmark Health Solutions to bring system defects to resolution while mitigating leakage developing workarounds until a solution can be implemented. The team interacts regularly with other areas within Payment Integrity to provide consulting on complex claims processes as well as provides adjustment support to the other areas including the vendor team and the clinical teams.

Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority. Plan and assign personnel, provide project oversight and ensure work accuracy on various Payment Integrity related claims audits.

Provide instructions and direction to other staff regarding technical solutions to meet business issues, as well as, anticipate impact and propose solutions. Performs analysis and documents audit requirements as well as assists in the design of system enhancements via the Change Request process to boost claims payment accuracy. Communicate issues and resolutions both within the Operational areas and outside including regular coordination with Financial Investigations and Provider Review (FIPR), Provider Relations, and Sales.

Ensure overall savings targets are achieved. This includes realignment of priorities to ensure resources are properly aligned to effectively achieve annual savings targets. Exercise, on a daily basis, discretion in the supervision of business analysts, development of processes and procedures to improve claims accuracy, influence systematic changes, provide strategic guidance and implement or recommend workable solutions. Regular latitude exists for contribution of significant input for important decisions.

Represents Highmark as the key contact for the Association mandated High Dollar Claims process which includes recommending process changes, providing feedback on current processes, influencing change and interacting with other Blue Plans on a regular basis. Other duties as assigned or requested.

Required:

Bachelor's Degree in Business Administration/Management
Substitutions: 6 years of related experience in lieu of a Bachelor's Degree
Preferred:
None

Required:

5 years in Operational Claims
3 years in a management or leadership role
Preferred: 3 years in Process Improvement
3 years in Medicare
1 year in Project Management

Required:

None
Preferred:
Project Management Professional (PMP)
Certified Fraud Investigator (CFE)
Certified Professional Coder (CPC)

Analytical Skills
Change Control
Claims/Benefit Systems
Financial Forecasting/Modeling
Microsoft Excel
Health Care Operations
Language (Other than English):
None

Travel Required:

0% - 25%

Position Type:
Office-Based
Teaches / trains others regularly
Rarely Travel regularly from the office to various work sites or from site-to-site
Rarely Works primarily out-of-the office selling products/services (sales employees)
Never Physical work site required Yes
Lifting: up to 10 pounds
Constantly Lifting: 10 to 25 pounds
Occasionally Lifting: 25 to 50 pounds

Rarely Disclaimer:
The job description has been designed to indicate…