Manager, Clinical Payment Integrity

Provides strategic and operational leadership for the Clinical Review & Recovery program within Payment Integrity. Manages Itemized Bill Reviews (IBRs), DRG validation, clinical coding audits, payment policy application, and post‑payment clinical claim reviews to ensure accurate reimbursement, regulatory compliance, and optimal recovery outcomes. Responsibilities Manages the review and analyses of clinical coding and medical policies and procedures and their impact on claim payments. Provides leadership and oversight for the Clinical Review & Recovery teams, strengthening the effectiveness of the clinical coding and claims payment auditing program. Monitors and analyzes department‑specific data reports, outcomes, and resource utilization, and leads the technical roadmap to refine business processes and optimize cost savings. Creates audit programs that identify issues with medical spending and recommends implementation of cost‑saving methodologies. Manages vendor relationships for clinical coding and claims payment audits, ensuring adherence to contractual limits and validating alignment between vendor deliverables and internal activities. Creates and maintains policies and procedures for clinical coding and claims payment audits performed by internal staff and recovery vendors. Monitors production data to stay abreast of trends and adjusts audit directions accordingly. Performs other duties as assigned. Education and Experience Bachelor's Degree in Nursing, Healthcare Administration or a related field. 8 years of progressive experience in health insurance operations, including 3 years in a supervisory or project‑management capacity. 3 years of experience in clinical coding and claims payment auditing. Professional Certification(s) Registered Nurse with a current license (required). Certified Professional Coder (CPC) or equivalent designation (preferred). Certified Professional Medical Auditor (CPMA) (preferred). Registered Health Information Administrator/Technologist (RHIA/RHIT) (preferred). Technical Skills and Knowledge Comprehensive knowledge of all facets of claims, medical procedures, terminology, and payment analysis with the ability to apply concepts to claim payment processes and auditing programs. Strong Microsoft Office and health insurance operations systems skills. Strong vendor management skills. Benefits Equipment provided: laptop, monitors, keyboard, mouse, and headset. Access to on‑site fitness centers or gym membership reimbursement. On‑site cafeteria serving breakfast and lunch at the Brooklyn, OH headquarters. Discounts at local businesses for employees. Cash rewards for shopping with customers. Business casual attire policy, including jeans. Employee bonus program. 401(k) with company match up to 4% plus additional contribution. Health Savings Account with company matching contribution. Medical, dental, vision, life, and disability insurance. Employee Assistance Program with counseling and coaching resources. Company holidays and up to 16 PTO days in the first year, with carry‑over options. Parental leave after 120 days of service for eligible employees. Career development programs and mentoring. Tuition reimbursement up to $5,250 per year. Diversity, inclusion, and welcoming culture with Business Resource Groups. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities. This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr Medical Mutual