Manager Program Integrity - Prepayment Auditing , Health Plan

Job Summary

The Prepayment Program Integrity Manager is responsible for the strategic and operational management of prepayment claims auditing programs designed to ensure payment and vendor accuracy. This role oversees prepayment review activities, vendor edit programs, provider appeal processes, and related auditing operations. The Manager leads a multidisciplinary team of clinical, coding, and audit professionals while partnering with internal stakeholders and external vendors to optimize claim review performance, cost savings opportunities, and provider engagement.

This position is accountable for ensuring that prepayment audit activities are conducted in a consistent, compliant, fact-based, and unbiased manner while balancing payment integrity objectives with provider experience and operational efficiency.

The Prepayment Program Integrity Manager is responsible for the strategic and operational management of prepayment claims auditing programs designed to ensure payment and vendor accuracy. This role oversees prepayment review activities, vendor edit programs, provider appeal processes, and related auditing operations. The Manager leads a multidisciplinary team of clinical, coding, and audit professionals while partnering with internal stakeholders and external vendors to optimize claim review performance, cost savings opportunities, and provider engagement.

This position is accountable for ensuring that prepayment audit activities are conducted in a consistent, compliant, fact-based, and unbiased manner while balancing payment integrity objectives with provider experience and operational efficiency. Manages day to day operations of Program Integrity Department. Ensures compliance with all federal, state, and other regulations while maintaining the integrity of all auditing data and reports. Conducts periodic compliance and performance reviews of auditor cases and activity.

Improves the balance of complexity versus-value to increase potential impact and returns. Successfully promotes and ensures audits are fact based, unbiased, comprehensive, and provides comprehensive informative findings.

Manages day to day operations of Program Integrity Department. Ensures compliance with all federal, state, and other regulations while maintaining the integrity of all auditing data and reports. Conducts periodic compliance and performance reviews of auditor cases and activity. Improves the balance of complexity versus-value to increase potential impact and returns. Successfully promotes and ensures audits are fact based, unbiased, comprehensive, and provides comprehensive informative findings.

• Manage the daily operations of the Prepayment Program Integrity function, including prepayment claim review and vendor edit oversight.
• Develop, implement, and continuously improve prepayment auditing strategies that support organizational payment integrity and compliance objectives.
• Monitor program performance, audit outcomes, operational metrics, and financial impact to drive continuous improvement.
• Establish and maintain policies, procedures, workflows, and controls related to prepayment claims auditing activities.
• Prioritize and manage multiple initiatives while meeting regulatory requirements, business objectives, and operational deadlines.

• Serve as the primary business owner for prepayment audit vendors and editing solutions.
• Oversee vendor performance, service delivery, operational effectiveness, contractual obligations, and financial outcomes.
• Collaborate with vendors to implement new edits, optimize existing auditing strategies, and improve program results.
• Monitor vendor accuracy, consistency,…