Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

　　Position Summary

　　The Manager of Payment Integrity is responsible for overseeing complex high-level and high dollar claim review and identifies areas of overpayment. This role oversees all claim auditing and recovery processes, identifies trends, and opportunities for process improvement. The manager oversees business partners supporting claims recovery and auditing, including payment integrity and fraud waste and abuse vendors.

　　Job Description

　　Key Outcomes:

　　Establishes, monitors, and continuously improves processes and supporting policies and procedures to ensure the timely and accurate processing of claims.

　　Responsible for ensuring the team complies with all model audit rule activities.

　　Oversees the Audit and Recovery team, tracks and reports all savings identified and recovered.

　　Consults and collaborates with the Director of Provider Operations to address issues contributing to inaccurate or inefficient processing of claims.

　　Identifies and submits high dollar claim referrals to other departments and vendors.

　　Provides vendor oversight and review and modification of vendor contracts. Manages vendor performance, and periodically surveys the market for alternative vendors.

　　Ensures vendor adherence to all policies and determines the need for new policies.

　　Oversees the development of annual department budgets consistent with strategic and financial goals.

　　Prepares and maintains information pertaining to Martin’s Point’s FWA program and produces management reports.

　　Prepares and facilitates requests for medical records to validate services rendered and claims submitted and evaluate the appropriateness of services/supplies billed.

　　Initiates and maintains communication with regulatory agencies, including presenting or assisting in the presentation of investigations and case findings.

　　Education/Experience

　　Bachelor’s degree preferred.

　　5 years management and/or leadership experience.

　　Experience in a health plan operations claims environment.

　　Skills/Knowledge/Competencies (Behaviors):

　　Knowledge of claims policies and procedures, including industry standards from Medicaid, CMS, and CCI Edits

　　Advanced skills in medical terminology, CPT/ICD-9/10 coding is preferred

　　Highly developed quantitative and qualitative analytical skills

　　Ability to articulate goals, plan and implement processes, and meet deadlines

　　Strong interpersonal skills, including professional communication, relationship building, and effective written and verbal communication

　　Solid understanding of standard claims processing systems, operations, and claims data analysis

　　Knowledge of HIPAA privacy regulation and rules necessary

　　Proficiency with Microsoft Office Suite applications

　　This position offers the opportunity to work remotely with quarterly and as needed visits to Portland, Maine.

　　We are an equal opportunity/affirmative action employer.

　　Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]

　　Martin’s Point Health Care is a progressive, not-for-profit organization providing care and coverage to the people of Maine and beyond. The organization operates six primary care health care centers in Maine and New Hampshire, accepting most major insurance plans. Martin’s Point also administers two health plans: Generations Advantage (Medicare Advantage plans available throughout Maine and New Hampshire), and the US Family Health Plan (TRICARE Prime® plan for active-duty and retired military families in northern New England, upstate New York, and western Pennsylvania). For more information, visit https://careers.martinspoint.org .