Provider Education Program Manager – Payment Integrity

Responsibilities

• Develop and maintain the health plan’s provider education program for coding, documentation, and billing integrity issues
• Establish program workflows, referral criteria, outreach templates, monitoring schedules, escalation pathways, and reporting standards
• Create standardized processes for provider identification, educational intervention, follow-up review, and referral to SIU when concerning behavior persists
• Analyze claims, coding, utilization, reimbursement, and provider billing data to identify outlier patterns
• Conduct targeted reviews to determine whether provider billing patterns warrant education or further escalation
• Draft and issue provider education letters that clearly describe identified billing concerns
• Conduct provider outreach calls and meetings to review findings, explain coding or documentation expectations, answer questions
• Perform quarterly and semiannual post-education monitoring to assess whether provider billing behavior changes
• Develop and administer a formal referral process to SIU for providers whose billing patterns do not improve

• Bachelor's degree or advanced degree (where required)
• 8+ years of experience in related field. In lieu of degree, 10+ years of experience in related field.
• CPC, CCS (Required), CEMA, CPMA (Strongly Preferred), CPIP (Nice to have) or similar coding/compliance certification.
• Experience in managed care, Medicare, Medicaid, Marketplace, or commercial health plan operations.
• Experience with provider education, payment integrity vendor outputs, post-pay review, over payment recovery, or FWA/SIU workflows.
• Advanced Excel, dashboarding, and data visualization skills.
• Strong knowledge of CPT, HCPCS, ICD-10, modifiers, documentation standards, reimbursement methodology, CMS guidance, and payer billing requirements.