Note: The job is a remote job and is open to candidates in USA. Sagility provides healthcare technology, transformation-driven BPM services, and healthcare domain expertise across areas including payment integrity, claims cost containment, and analytics. The Manager, Payment Integrity Program Development & Innovation leads a team developing and optimizing complex healthcare audit programs, claim selection methodologies, and recovery strategies while collaborating with cross-functional and client-facing teams.
Responsibilities
- Lead, mentor, and develop a team of Subject Matter Experts responsible for complex audit program design and implementation
- Foster a culture of accountability, collaboration, innovation, and continuous improvement
- Establish performance expectations and monitor team productivity, quality, and operational effectiveness
- Support recruitment, onboarding, professional development, and succession planning initiatives
- Develop and maintain a portfolio of complex payment integrity audit concepts and recovery initiatives
- Identify emerging overpayment risks and reimbursement vulnerabilities across multiple healthcare claim types
- Evaluate opportunities based on financial impact, operational feasibility, recovery potential, and client value
- Collaborate with internal stakeholders to prioritize and implement new audit programs
- Partner with analytics and technology teams to design, validate, and optimize claim selection methodologies and audit algorithms
- Define business requirements and selection criteria for complex audit programs
- Monitor audit performance and continuously refine targeting strategies to improve recovery yield and audit accuracy
- Evaluate program metrics, including hit rates, recovery rates, overturn rates, and return on investment
- Provide subject matter expertise on healthcare reimbursement methodologies, payment policies, coding guidelines, and industry best practices
- Ensure audit concepts and methodologies comply with applicable regulatory, contractual, and operational requirements
- Serve as an escalation point for complex audit findings, provider disputes, and appeals support activities
- Maintain current knowledge of Medicare, Medicaid, Commercial, and Managed Care reimbursement methodologies
- Partner with Operations, Clinical, Appeals, Product, Analytics, Compliance, and Client Services teams to support successful program implementation
- Participate in client-facing discussions related to audit methodologies, findings, performance metrics, and program strategy
- Support sales, implementation, and proposal efforts by providing subject matter expertise and audit program recommendations
- Contribute to strategic initiatives that enhance payment integrity capabilities and client outcomes
Skills
- Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, Business Administration, Finance, or a related field
- Minimum of 5 years of healthcare Payment Integrity experience
- Minimum of 3 years of leadership experience managing audit, coding, clinical, payment integrity, or SME teams
- Demonstrated experience developing complex healthcare audit concepts and claim selection methodologies
- Strong knowledge of healthcare reimbursement methodologies, claims adjudication, coding systems, and payment integrity operations
- Experience collaborating with analytics, operations, and appeals teams to implement audit programs
- Healthcare Reimbursement Methodologies
- Payment Integrity Program Management
- Complex Audit Concept Development
- Claims Analytics and Audit Selection Strategies
- Regulatory Compliance and Healthcare Policy Knowledge
- Leadership and Team Development
- Strategic Planning and Problem Solving
- Project and Portfolio Management
- Strong Written and Verbal Communication Skills
- Client Relationship Management
- Process Improvement and Operational Excellence
- Current unrestricted RN license
- RHIA, RHIT, CCS, CPC, COC, CIC, CRC, or other applicable healthcare industry certification
- Experience with Medicare, Medicaid, Commercial, and Medicare Advantage reimbursement methodologies
- Experience supporting client implementations, provider engagement activities, and RFP responses
- Experience with healthcare data analysis, audit technology platforms, and complex claims analytics
Benefits
- Fully Remote
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