Associate Director - Payment Integrity Operations

Associate Director Of Optumcare Payment Integrity Operations

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing Together.

The Associate Director of OptumCare Payment Integrity operations will serve as an operational leader for Payment Integrity correct coding. Including vendor implementations, vendor management and ongoing operational delivery functions. The AD will lead a team that includes both operational resources and business analysts. They will act as the lead coding expert; driving multi-year growth strategies, collaborating with business partners and markets, creating staffing and financial forecasting, monitoring KPIs, enabling automation, as well as ongoing opportunity identification and benefit analysis. Functions may include claims processing, capacity analysis planning and reporting, data integrity, CMS and compliance adherence, vendor management, inventory management, rule validation and approval, medical expense reduction, and forecasting. The AD will work with numerous matrix partners to manage deliverables, provide policy expertise, communicate change, and manage escalations.

The Associate Director of PI correct coding will need to achieve gross and incremental savings targets through program integrity oversight, effective capacity planning, inventory management, vendor management, growth strategy, automation, and operational discipline.

Primary Responsibilities:

• Provide leadership and coding expertise for Payment Integrity teams to ensure delivery on gross and incremental savings targets
• End to end process ownership for coding outcomes
• Identify, implement, and report opportunities to improve processes, procedures, systems
• Develop strong partnership with matrixed partners and stakeholders
• Provide market-facing support to support escalations, communicate change, and deliver budgeted savings
• Collaborate with a wide variety of matrix partners including but not limited to; healthcare economics, network management, claims operations, compliance, and regional and national medical directors, finance, internal and external vendors, UHC, OGA
• Lead program outcomes related to correct coding services. Coordinating with vendors to improve performance, expand scope of services, reduce abrasion, and increase savings
• Align staffing volumes/needs with savings forecasts and volumes
• Deliver expert vendor management practices to ensure that operational processes are standardized across multiple vendors and internal programs
• Drive favorable algorithm outcomes across 15 integrated markets and 2 non-integrated.
• Document and communicate outcomes of claims investigations/overpayment/prepayment reviews to applicable stakeholders
• Manage multiple line of business with varying regulations and compliance rules
• Effectively plan staff responsibilities and manage vendor deliverables to meet department goals
• Lead and collaborate with claim operations team to identify 'shift left' opportunities to drive reductions in recovery adjustments
• Manage issues and escalations applicable to correct coding
• Manage domestic and OGA work inventories
• Demonstrate understanding of applicable federal, state, and local compliance regulations (e.g., DOI, DOL, Healthcare Reform/PPACA, CMS) and ensure adherence
• Ensure all operational metrics are met
• Closely monitor provider abrasion and manage within controls; driving quality improvement, true positive increases, and appeal rate reductions.
• Deliver business requirements for savings and operational metrics dashboard reports
• Understanding of claims processing end-to-end
• Lead implementation management for any program expansions, market expansions
• Effectively manage staff responsibilities and manage activities
• Develop cost benefit analysis for proposed program expansions
• Ideate and identify new opportunities for assigned programs

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Certified Coder (ex., CPC, CIC, CIMC)
• 7+ Years of healthcare leadership experience
• 7 + years experience working within a health plan and/or managed care business operations
• 3 + years in leadership role with experience in management of front line staff
• 3+ years experience working with clinicians (MD)
• 3 + years of experience in forecasting and budget management
• 3 + years developing and managing operational metrics
• 3+ years of payment integrity experience: prepayment and/or post-payment processes
• 2+ years client management experience

Preferred Qualifications:

• Lean Six Sigma (Green belt/Kaizen)
• Provider Office / Practice Administration experience
• Clinical credential (LPN, LVN, RN)
• Experience in fraud detection, analytic methodologies, payment policies, and provider contracts

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary for this role will range from $110,200 to $188,800 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.