Manager Program Integrity - Prepayment Auditing , Health Plan

Location:

Work from home (Pennsylvania)

Shift: Days (United States of America) Scheduled Weekly

Hours:

40 Worker Type:
Regular Exemption Status:
Yes

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.

Program Leadership & Operations 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, turnaround times, and appeal outcomes through ongoing quality assurance and performance reviews. Lead regular business reviews and ensure vendor activities align with organizational goals and compliance standards.

Oversee prepayment claim auditing activities involving professional, facility, and ancillary claims. Ensure audit methodologies, clinical reviews, and coding determinations meet industry standards and regulatory requirements. Evaluate audit results, identify trends, and recommend corrective actions to improve payment accuracy and reduce improper payments. Promote fact-based, objective, and defensible audit determinations supported by clinical and coding documentation. Conduct periodic reviews of audit performance, quality findings, and operational effectiveness.

Manage the prepayment audit appeal process and ensure timely, consistent, and compliant resolution of provider disputes. Partner with clinical, legal, compliance, provider relations, and operations teams to support appeal review and determination processes. Analyze appeal trends and outcomes to identify opportunities for audit refinement, provider education, and policy improvement. Ensure appeal decisions are supported by clinical evidence, coding guidelines, contractual requirements, and regulatory standards.

Lead and develop a team of nurses, coders, auditors, analysts, and payment integrity professionals. Provide guidance, coaching, and performance management to support staff development and operational excellence. Ensure team members maintain current knowledge of coding standards, reimbursement methodologies, payment integrity practices, and applicable regulations. Foster collaboration across clinical, coding, compliance, and operational teams.

Ensure all prepayment auditing activities comply with federal and state regulations, CMS requirements, contractual obligations, and organizational policies. Serve as a subject matter expert on payment integrity, prepayment auditing, coding compliance, and audit governance. Support internal and external audits, regulatory inquiries, and compliance reviews. Identify emerging risks, industry trends, and opportunities to strengthen prepayment controls and payment accuracy programs.

Develop and present executive-level reporting on audit…