Clinical Manager - Payment Integrity

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 data analytics to support client and carrier requests Partner with internal teams to improve accuracy using data analysis and carrier feedback Provide clinical expertise to 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 and identify trends, gaps, and opportunities for improvement Prepare carrier responses on open and active referrals Lead carrier calls, referral calls with carrier network and clients Maintain accurate records of clinical policies, workflows, and quality initiatives Lead, manage and mentor the department’s Clinical 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 to identify patterns, risks, and opportunities Develop and maintain dashboards, 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 that impact operations, payments, or partner experience Develop data visualizations with Excel or data visualization tools Requirements Active clinical license (RN, LPN/LVN or other relevant credential) preferred or inactive license with relative clinical experience or 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+ years in TPA/Carrier claims processing or payment integrity related areas 5+ years of experience in healthcare administration, billing, claims processing, clinical auditing, payment integrity, or related areas Working knowledge of medical 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 data from 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 Core Competencies Demonstrates expertise in clinical data analysis, claims processing, and operational workflows, with a strong focus on compliance and quality improvement. Proficient in leading teams and collaborating across functions to enhance clinical outcomes and efficiency. Highest-signal resume keywords Active Clinical License CPC Certification Claims Processing Experience Data Analysis Skills Leadership Experience ATS Optimization Keywords Hard Skills Medical Claims Data Clinical Auditing Billing Accuracy NCCI Guidelines Data Visualization Healthcare Workflows Clinical Documentation Review Performance Metrics Monitoring SOP Development Clinical Process Improvement Soft Skills Attention to Detail Clear Communication Empathy Analytical Thinking Team Collaboration Certifications & Qualifications CPC CCS Industry Keywords Healthcare Administration TPA Payment Integrity Claims Processing Medical Insurance Carrier Tools & Technologies Excel Data Visualization Tools #J-18808-Ljbffr Jobtailor