Payment Integrity Program Manager

Accountabilities: Perform complex and escalated inpatient Payment Integrity audits, including clinical validation, DRG coding validation, readmission reviews, and hospital bill audits, while documenting clear and defensible rationale for determinations. Provide oversight and guidance to stateside and offshore teams and external vendors through calibration sessions, feedback, education, and ongoing quality monitoring. Develop and maintain program-specific training materials, audit guidance, review standards, and supporting documentation. Conduct quality reviews and trend analysis to verify coding, clinical, and audit findings and ensure alignment with regulatory, contractual, and organizational requirements. Monitor program metrics, dispute trends, turnaround performance, and vendor results, identifying root causes and recommending corrective actions and continuous improvements. Serve as a subject matter expert for assigned programs, partnering with clinical, coding, audit, operational, and leadership teams to resolve complex issues and escalations. Support dispute and appeals activities, including escalation reviews, audit-rationale assessments, and corrective-action planning. Contribute to the implementation of new audit concepts, review methodologies, and program enhancements as business and regulatory requirements evolve. Requirements 2–3 years of experience in healthcare auditing, Payment Integrity, coding review, clinical documentation review, or healthcare compliance. Strong clinical and inpatient coding expertise, with CCS, RHIA, RHIT, RN, or equivalent inpatient coding or clinical-validation experience required. Demonstrated expertise in inpatient DRG assignment and validation, including ICD-10-CM coding, principal and secondary diagnoses, MCC/CC identification, POA indicators, clinical documentation review, severity of illness, risk of mortality, and readmission logic. Experience reviewing medical records to assess audit accuracy, coding and clinical correctness, compliance, and defensibility. Experience working within structured audit programs, applying defined criteria, documenting rationale, and maintaining consistency across audit outcomes. Ability to interpret clinical and coding documentation, identify documentation gaps or discrepancies, and use evidence to support audit decisions. Experience collaborating across clinical, coding, audit, and operational functions within complex healthcare environments. Strong analytical and problem-solving skills, including the ability to identify audit trends, root causes, and documentation gaps affecting quality and performance. Proven experience training others on Payment Integrity auditing practices. Strong organizational and operational discipline, with the ability to manage multiple priorities and meet deadlines. Bachelor’s degree preferred. Strong leadership, communication, and interpersonal skills for working with internal and external stakeholders. Experience managing offshore vendors is preferred. Familiarity with AI tools, automation, or LLM-based workflows in operational environments is a plus. Benefits Annual salary range of $73,000–$120,000 , with the final offer based on experience, qualifications, certifications, education, skills, and work location. Employer-sponsored health, dental, and vision coverage with low or no employee premiums. Generous paid time off. $100 monthly mobile or internet stipend. Stock options for eligible employees. Bonus eligibility for applicable roles. Parental leave program. 401(k) retirement program. Additional benefits and total rewards for eligible full-time employees. Fully remote work environment.