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Director, Payment Integrity - Hybrid

Director, Payment Integrity - Hybrid

Parkland Health and Hospital SystemIrving, TX, United States
2 days ago
Job type
  • Full-time
Job description

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family.  PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area.  PCHP works to fulfill of our mission by empowering members to live healthier lives.  By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job—it’s a passion to serve and improve lives every day.

Primary Purpose

Provides leadership oversight and directs the operations for the Program Integrity department and associated functions with focus on claims editing, fraud, waste, and abuse (FWA) prevention, and payment accuracy. Accountable for supporting Parkland Community Health Plan’s (PCHP) commitment to operational excellence, cost containment, and adherence to state and federal requirements. As the Director of Payment Integrity / Program Integrity, this is a great opportunity to join PCHP. We prioritize our Members, foster creativity and innovation, and simplify the Provider experience.

Minimum Specifications

Education

  • Bachelor’s degree in business administration, healthcare Administration, or related discipline required.

Experience

Required

  • Five (5) years of management experience required.
  • Eight (8) years of experience in Payment Integrity Audit and Recovery with knowledge of audit strategies such as Data Mining, Clinical Medical Record Review, and Bill Audit Recovery / Program Integrity experience preferred.
  • 2 years of experience in a Managed Care health plan or state agency required
  • Knowledge of ICD-10 and CPT / HCPC coding guidelines and terminology required.

    • Preferred

  • 5 Years of Texas Medicaid, Managed Care Health Plan or State agency experience preferred.
  • Equivalent Education and / or Experience
  • Eight (8) years of experience in a comparable position working in Texas Medicaid or Medicaid Managed Care may be considered in lieu of a bachelor’s degree.

    • Certification / Registration / Licensure

  • Project management or Six Sigma certification preferred.
  • Required Tests for Placement

    • Skills or Special Abilities

  • Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines and with a variety of constituents as well as the ability to articulate complex information in understandable terms.
  • Demonstrated ability to coach and influence for results.
  • Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships with diverse groups across and beyond the organization.
  • Strategic thinking and long-range planning skills with the ability to lead major organizational initiatives, accomplish results, and achieve measurable outcomes or goals.
  • Ability to work in challenging situations involving competing interests, and high level-interdisciplinary groups.
  • Excellent time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
  • Strong analytical and problem-solving skills.
  • Knowledge of Texas Medicaid (STAR, STAR Kids / CHIP) program, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.
  • Sound business acumen.
  • Proficient Microsoft Office and computer skills.

    • Responsibilities

    Operations

  • Develops policies and procedures for an effective program integrity program that aligns with State and Federal laws.
  • Responsible for the discovery, validation, recovery, and adjustments of claims overpayments.
  • May do all or some of the following in relation to cash receipts, cash application, claim audits collections, overpayment vendor validation, and claim adjustments applicable to Medicaid, CHIP, Medicare, and Marketplace claims.
  • Audits paid claims for overpayments using various techniques including systems-based queries, specialized reporting, or another research.
  • Maintains and reconciles department reports for outstanding payments identified, collected, past-due, uncollectable, and auto-payment recoveries.
  • Assists with Coordination of Benefit, eligibility, DRG validation.
  • Responsible for complex issues such as coordination of benefits and medical policies.
  • Works closely with departments within the health plan to identify and correct contractual issues when applicable.
  • May perform collection activities to ensure the recovery of overpayments and maintenance of unprocessed cash and accounts receivable processes and all other cash applications as required.
  • Prepares and provides write-off documents that are deemed uncollectible, or collection efforts are exhausted for write-off approval.
  • Works with Finance to complete accurate and timely posting of provider and vendor refund checks and manual check requests to reimburse providers.
  • Examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control.
  • Reviews and conducts analysis of claims and medical records prior to payment and uses required systems / tools to accurately document determinations and continue to next step in the claim’s lifecycle.
  • Research new healthcare related questions as necessary to aid in investigations and stays abreast of current medical coding and billing issues, trends, and changes in laws / regulations.
  • Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern.
  • Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.
  • Prepare and deliver clear, concise, and actionable reports and presentations to executive leadership.

    • Strategy

  • Leads the strategy, implementation, and oversight of programs that assure provider payments are appropriate and accurately reflect the plan’s policies, provider contracts, and member benefits.

    • Quality

  • Integrates health literacy principles into all communication including Members and Providers.
  • Supports strategies that meet clinical, quality and network improvement goals.
  • Promotes the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.
  • For staff in clinical roles, foster collaborative relationships with members and / or providers to promote and support evidence-based practices and care coordination.

    • Regulatory

  • Develops processes to maintain compliance with regulatory agencies and accrediting bodies. Ensures operations are carried out in compliance with these regulations.
  • Works collaboratively with others to validate and sustain compliance with regulatory and accreditation standards.
  • Conducts routine compliance audits identifying gaps and implementing remediation plans as necessary.
  • Works collaboratively with leadership and / or PCHP Compliance to investigate and respond to matters of concern or alleged violations taking corrective action as necessary.
  • Provides timely and accurate responses to requests for information from regulatory agencies and accrediting bodies.

    • Fiscal Management and Operating Budget

  • Operationally responsible for the financial performance of assigned area(s).
  • Promote activities to achieve operational efficiency.
  • Manage the approved budget through frequent and regular monitoring. Implement written action plans to address variances adjusting strategies as necessary to meet budgetary targets.
  • Consider operational outcomes and financial implications when making recommendations to implement new programs or modify current programs.
  • Manage staffing levels within established targets.

    • Talent Management

  • Recruits and retain diverse talent with a variety of backgrounds, skills, experiences, and viewpoints that reflect the communities we serve.
  • Promotes and support a culturally welcoming, inclusive, collaborative, and highly engaged work environment where everyone feels empowered to bring their full, authentic selves to work.
  • Accountable for orientation, ongoing education and training, and competency verification for all employees.
  • Ensures Human Resource metrics (i.e., retention, vacancy, engagement) meet established targets. Utilize workforce metrics to monitor, identify, and respond to workforce trends.
  • Timely completion of employee performance appraisals.
  • Conducts regular meetings, inform team of changes in policy or procedure, and provide information regarding overall strategy and direction of the health plan.
  • Mentors, coach, and support direct reports with building teamwork, professional development, and education to achieve optimal performance and develop talent.
  • Ensures employee engagement survey participation rates and results meet established targets.
  • Mandatory requirements are completed timely by employees.
  • Required licensure, certification, and / or registry are current and in good standing for all employees.
  • Employee performance is monitored and managed. Consult with the Office of Talent Management as appropriate regarding employee performance concerns and disciplinary action.

    • Professional Accountability

  • Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
  • Adheres to organizational policies, procedures, and guidelines.
  • Completes assigned training, self-appraisal, and annual health requirements timely.
  • Adheres to hybrid work schedule requirements.
  • Attends required meetings and town halls.
  • Recognizes and communicate ethical and legal concerns through the established channels of communication.
  • Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
  • Maintains confidentiality at all times.
  • Performs other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.

    • Job Accountabilities

  • Identifies and analyzes the design of jobs, work processes, workflows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of PCHP.
  • Stays abreast of the latest developments, advancements, and trends in the field by attending seminars / workshops, reading professional journals, actively participating in professional organizations, and / or maintaining certification or licensure. Integrates knowledge gained into current work practices.
  • Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.
  • Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives that have been established for the department.
  • Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of PCHP.
  • Selects, trains, schedules, motivates, supervises, and evaluates employees making recommendations for disciplinary actions up to and including termination, to ensure maximum utilization of individual and group capabilities. Ensures that assigned employees receive opportunities to further their knowledge.

    • #L1-NB1

    Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.

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    Director Payment Integrity Hybrid • Irving, TX, United States

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