Director, Payment Integrity

Description

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration - because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

The Director of Payment Integrity will lead efforts in claims cost management identification and implementation of cross functional opportunities resulting in operational efficiency, claim payment accuracy and adherence to industry standard practices. Initiatives will be delivered via internal operational processes and performance management as well with the use of external vendors.

This leadership position is accountable for cost containment strategy development and execution via payment integrity business processes (e.g., reimbursement policy development / maintenance, high dollar audits, health care error / waste / abuse detection and intervention, and implementation and management of claims editing and pricing software) to achieve $50MM+ in annual medical expense savings; plays a lead role on the company's Affordability Committee in relation to Policy & Configuration; recruits and manages insourced and outsourced talent.

The most critical skills and experience required for this role involve : a) designing and implementing a strategic capability development roadmap (new process, technology, people capabilities) for the departments and functions discussed above, while b) simultaneously optimizing near-term operational performance (within fixed process, technology, people constraints) to ensure key performance indicators (KPIs) and appropriate regulatory / compliance standards are met. Performs other duties assigned.

Key Accountabilities

Strategic Capability Development

• Develops Payment Integrity future functional strategies and capability roadmaps; identifies how these functions must change / evolve to support Medica 2022-2024 Strategic Plan, mostly notably around two requirements : a) Operational Service Excellence, and b) Ability to Scale / Cost Efficiency. Directs and incorporates industry benchmarks is building these strategies / roadmaps, effectively networking with industry counterparts or vendors to obtain external information needed to shape these strategies and ensure external market / competitive environment is appropriately taken into account. Maintains three-year future state services strategy, encompassing necessary Business Process, Technology Use, and People evolution that will achieve the expected new Key Performance Indicators / KPIs outlined in the 3 Year Operations Plan. Beyond identifying capability improvements, must also establish priorities for the multi-year work / related individual projects. This work will require business case development for each service transformation / improvement
• Once the strategy / business cases are developed, maps each service strategy / business case to any potential existing or planned Medica program that might serve as a dependency or catalyst for the progression of strategic work. Thus, must be able to effectively identify and negotiate where inter-dependency exists, and how to navigate a) shared scope / funding, or b) separate funding but integrated scope circumstances
• Leads and / or supports related (Six Sigma / LEAN) process engineering efforts that are either stand-alone or integrated with technology projects / enhancements. Employs quantitative analysis methodology to perform data, cost and benefit, and / or process measurement analysis
• Develops and manages change management discipline and associated processes with leaders / staff throughout the organization; ensures appropriate communication protocols are used throughout the strategy, planning and implementation lifecycle

Operations Performance Management

Required Qualifications

Preferred Qualifications

Ability to provide work direction and coaching to individuals not under direct authority

This position is a Remote role.To be eligible for consideration, candidates must have a primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MD, ME, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI

The full salary grade for this position is $111,200 - $190,600. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $111,200 - $166,740. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and / or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US : Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.

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, please review the Know Your Rights notice from the Department of Labor.