Clinical Manager- Payment Integrity

Position Overview

The Manager of Payment Integrity serves as the bridge between clinical expertise and 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, this role leads, manages and mentors the department’s Clinical Analysts.

Responsibilities

• Review medical records for billing accuracy and coding guidelines
• Understand and apply NCCI guidelines and be able to recognize common claims errors
• Provide data analytics to support client and carrier requests
• Partner with internal teams to improve accuracy using data analysis and carrier feedback
• Support operational workflows including reviewing claims data and medical records
• Collaborate with cross-functional teams to design and refine clinical processes that improve outcomes and efficiency
• Maintain accurate records of clinical policies, workflows, and quality initiatives
• Lead, manage and mentor the department’s Clinical Analyst(s)
• Translate clinical insights into operational recommendations that improve performance, cost efficiency, and service quality
• Develop and maintain dashboards, reports, and performance summaries for leadership
• 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
• Participate in cross-functional meetings, business reviews, and strategic planning sessions
• Support the development of SOPs, training materials, and process improvements
• Provide clear, empathetic communication to support escalations, case reviews, and program updates

Qualifications

• 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 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