Clinical Manager- Payment Integrity

Position Overview:

The Manager of Payment Integrity servesas the bridge between clinicalexpertiseand business operations. This role evaluates payment integrity processes as it relates to carrier reimbursements, supports operational decision‑making, ensures quality and compliance, and partners with internal and external stakeholders to improve outcomes, efficiency, and experience. The Manager of Payment Integrity uses clinical knowledge, data insights, and process thinking to guide program strategy, resolve escalations, and support continuous improvement across the organization.

Additionally, thisrole leads, manages and mentors the department’s Clinical Analysts.

• Review medical records for billing accuracy and coding guidelines

• Have experience reviewing both facility and provider claims

• Understand and apply NCCI guidelines and be able to recognize common claims errors

• Review clinical documentation, guidelines, and cases to ensure accuracy, compliance, and alignment with standards

• Provide dataanalyticsto support client and carrier requests

• Partner with internal teams to improve accuracy using data analysis and carrier feedback

• Provide clinicalexpertiseto support operational workflows including reviewing claims data medical records

• Partner with cross‑functional teams to design and refine clinical processes that improve outcomes and efficiency

• Monitor clinical quality metrics andidentifytrends, gaps, and opportunities for improvement

• Prepare carrier responses on open and active referrals

• Lead carrier calls, referral calls with carrier network and clients

• Maintainaccuraterecords of clinical policies, workflows, and quality initiatives

• Lead, manage and mentor the department’sClinical
  
  Analyst(s)

• Collaborate with IT and serve as the liaison on business and reporting requirements for departmental IT initiatives

• Translate clinical insights into operational recommendations that improve performance, cost efficiency, and service quality

• Collaborate with Operations, Payment Integrity, and other teams to resolve escalations

• Support the development of SOPs, training materials, and process improvements

• Analyze clinical and operational data toidentifypatterns, risks, and opportunities

• Develop andmaintaindashboards, reports, and performance summaries for leadership

• Serve as a clinical subject‑matter expert for internal teams, carriers, partners, and vendors

• Provide clear, empathetic communication to support escalations, case reviews, and program updates

• Participate in cross‑functional meetings, business reviews, and strategic planning sessions

• Develop and deliver training for internal teams on clinical guidelines, workflows, and quality expectations

• Support onboarding of new team members by providing clinical context and program knowledge

• Ensure teams understand clinical requirements thatimpactoperations, payments, or partner experience

• Develop data visualizations with Excel ordata visualization tools

• Active clinical license (RN, LPN/LVN or other relevant credential) preferredor inactive license with relative clinical experienceor relative clinical data experience

• Bachelor’s degree in Nursing, Healthcare Administration, Business, or related field; advanced degree a plus

• At least one of the following certifications: CPC, CCS, or similar clinical/coding credential

• 5+ yearsin TPA/Carrier claims processing or payment integrity related areas

• 5+ yearsyearsof experience in healthcare administration, billing, claims processing, clinical auditing, payment integrity, or related areas

• Working knowledge ofmedical claims data, medical procedures, and healthcare workflows

• Strong attention to detail and ability to communicate clearly in writing and verbally

• Experience working with commercial health plans is a plus

• Solid analytical and critical‑thinking skills

• Preferred- experience reviewing medical records and/or claims datafrom a payor perspective (preferably in a medical insurance carrier setting)

• Experience working in a cross‑functional business environment strongly preferred

• Experience as a people leader/managing a team

• Strong clinical judgment with the ability to apply guidelines and standards consistently

• Analytical…