Program Manager

About the role

The Payment Integrity Program Manager is responsible for the management and oversight of the DHP payment integrity program, ensuring accurate claims processing in compliance with contracts and state and federal regulations. This role identifies and mitigates improper payments, identifies trends of potential fraud, waste, and abuse, and implements robust strategies for cost containment and recovery.

Responsibilities

• Maintains utmost level of confidentiality at all times and adheres to health plan policies and procedures
• Tracks and analyzes claims data to identify trends in provider billing and the core claims system adjudication
• Executes audits of claims adjudication to ensure compliance with relevant contracts and manuals
• Partners with the DHP Special Investigative Unit (SIU) to report suspicious provider billing patterns for further investigation
• Collaborates with internal partners to ensure provider contract rates, fee schedules, and rate changes are configured appropriately in the core claims system
• Manages the relationship with external vendors performing post-payment review of the appropriateness of hospital APR DRG code submission
• Performs root cause analysis of provider refund submissions to identify process improvement opportunities
• Monitors the resolution of provider submitted complaints to identify opportunities for improvement in claim accuracy
• Identifies opportunities for pre or post payment reviews to ensure appropriate reimbursement
• Maintains dashboards and reports key performance indicators to monitor effectiveness of payment integrity program
• Monitors Texas Medicaid and Health Partnership (TMHP) and HHSC Bulletins and Notices to identify rate, benefit, and administrative changes

Requirements

• Associate's degree (A.A.) from a two-year college or technical school in Healthcare Administration, Business, Finance, or a related field
• Three to five years related experience in health plan payer operations, managed care, or health plan reimbursement
• Strong working knowledge of managed care medical coding systems (CPT, HCPCS, ICD-10, DRG)
• Two years or more experience with Medicaid reimbursement methodologies, NCCI edits, Medicaid billing guidelines, and state Medicaid payment rules
• Experience with Texas Medicaid Managed Care is preferred
• Experience owning operational projects from concept to execution, especially in the areas of provider reimbursement and/or claims payment integrity
• Demonstrated ability to work independently and apply business judgement in a high regulated, cross-functional environment
• Advanced proficiency in Excel, with experience with Power BI or SQL preferred