Director Payment Integrity & Encounters - Full Time, Days (Remote)

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Director, Payment Integrity & Encounters is responsible for leading the development and execution of payment integrity strategy and activity across the Organization. This role will focus on payment process optimization and management, identifying and leveraging technology and data to improve the quality and minimize process cost of Claims. The position will drive strategic planning, operational excellence and accuracy of the claims payment driving lower encounter rejection. This position will own the generation of key performance metrics and all operational and regulatory reporting by working in collaboration with IT. The Director will collaborate with other Prospect departments and personnel to develop strategies to identify, mitigate and optimize operational and financial gaps. This role will also be responsible for the management and oversight of end-to-end encounter workflow.

Job Responsibilities/Duties

• Oversee, monitor and manage the end-to-end encounter data management lifecycle to drive accuracy, timeliness and improve overall PMPY metrics
• Ensure Encounter end to end processes and performance are aligned with the Health Plan, CMS, DHCS, and all regulatory agencies' requirements, needs & standards
• Create and manage dashboards, KPIs, SOPs, Policies & Procedures to ensure and improve inbound & outbound encounter submissions performance
• Drive initiatives to develop best in class methodologies for encounter data management
• Create and implement strategies to identify the business and operation opportunities for both inbound & outbound processes to improve overall performance and help reduce encounter rejections
• Develop and implement strategy to drive claims payment accuracy, efficiency and quality using industry best practices
• Collaborate with Claims, Configuration, IT Ops & other BUS (as needed) to identify areas of opportunities from system and process standpoint for driving claims pricing accuracy
• Effectively utilize business intelligence and data analytics to monitor operations' performance and identify/implement business solutions to improve process and quality gaps including but not limited to auto-adjudication
• Oversee the development and implementation of cross-functional operations improvements including standardization and controls design to ensure planned results are delivered
• Lead, drive, maintain & oversee all KPI dashboards for Claims, Config & Encounters
• Collaborate with Claims and Configuration to identify root cause and develop prevention plans for any metrics variance against the goals
• Ensure all scheduled and ad-hoc reports for Claims including universe listings for audits are delivered accurately & timely
• Collaborate with IT to automate recurring Claims & Configuration reporting
• Responsible for producing Claims impact analysis reports and automation of frequently used reports
• Build and maintain productive & collaborative intradepartmental relationships with department leads (Claims, Configuration, IT Ops, UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Recovery, Compliance, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution and drive operational excellence
• Collaborate with the Claims, Configuration and IT Ops Teams to develop a robust strategy for root cause analysis and prevention plan for any claim related issues
• Drive and collaborate with IT to create/ develop tools to effectively maintain, update, or revise all scorecards, dashboards, and reports, as necessary
• Collaborate with the Configuration and IT Teams to continuously improve upon system configuration/ rules set up for accurate and effective claims adjudication
• Recommend changes for system design, rules, and workflows affecting Claims processing
• Proactively contribute to Claims testing/ audit strategy development and provide timely feedback based on day-to-day findings
• Conduct special projects including business analyses, strategic planning, and implementation efforts on new business acquisitions and changing business and organizational requirements
• Develop and execute strategic initiatives and programs to enhance existing functions and develop new processes in support of corporate initiatives and requirements

Minimum Education: Bachelor's degree or equivalent experience preferred with healthcare administration focus required.

Minimum Experience: Ten plus (10+) years of experience in the healthcare industry required. Six to eight (6-8) years claims administration experience in a Health Plan/IPA/MSO setting required. Five (5+) years of experience in managing claims operations in a large managed care environment required. Five plus (5+) years of experience in managing encounter data in a large managed care environment required. Proven success in improving key performance metrics, including process improvement, cost reduction and improving efficiency. Demonstrated leadership skills, ability to coach, mentor and foster a culture of achievement. Strong independent decision-making, influencing and analytical skills. Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines. IDX experience, Cotiviti Experience, Burgess Experience preferred. Worked with Clearinghouses like Trans Union & Office Ally preferred. Experience with managing offshore Vendors preferred. Core System implementation experience preferred. Core System configuration experience preferred.

Req. Certification/Licensure: None.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:

• Company 401K
• Medical, dental, vision insurance
• Paid time-off
• Life insurance

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www.eeoc.gov/