Manager, Payment Integrity Program Development & Innovation is responsible for leading a team of healthcare payment integrity experts focused on developing, implementing, and optimizing complex audit programs that identify and recover healthcare overpayments. This role oversees the creation of audit concepts, claim selection methodologies, and recovery strategies across inpatient, outpatient, professional, specialty, and durable medical equipment (DME) claim types.
The Manager serves as a key leader within the Payment Integrity organization, partnering with clinical, operational, analytics, appeals, and client-facing teams to drive innovative audit solutions, maximize recovery opportunities, and ensure program effectiveness. This position plays a critical role in expanding audit capabilities, improving financial outcomes, and delivering exceptional value to clients.Manager, Payment Integrity Program Development & Innovation

Manager, Payment Integrity Program Development & Innovation is responsible for leading a team of healthcare payment integrity experts focused on developing, implementing, and optimizing complex audit programs that identify and recover healthcare overpayments. This role oversees the creation of audit concepts, claim selection methodologies, and recovery strategies across inpatient, outpatient, professional, specialty, and durable medical equipment (DME) claim types.
The Manager serves as a key leader within the Payment Integrity organization, partnering with clinical, operational, analytics, appeals, and client-facing teams to drive innovative audit solutions, maximize recovery opportunities, and ensure program effectiveness. This position plays a critical role in expanding audit capabilities, improving financial outcomes, and delivering exceptional value to clients.

Essential Responsibilities

Leadership & Team Development

• 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.

Audit Program Development

• 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.

Claim Selection Strategy

• 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.

Regulatory & Technical Expertise

• 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.

Client & Cross-Functional Collaboration

• 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.

Required Qualifications

Education

• Bachelor’s degree in Nursing, Health Information Management, Healthcare Administration, Business Administration, Finance, or a related field.

Experience

• 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.

Preferred Qualifications

• 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.

Knowledge, Skills & Abilities

• 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

Success Measures

Success in this role will be measured by:

• Development and implementation of new audit concepts
• Recovery yield and financial performance of audit programs
• Improvement in audit hit rates and return on investment
• Team productivity, quality, and engagement
• Client satisfaction and retention
• Regulatory compliance and audit defensibility
• Innovation and continuous improvement outcomes

Sagility is an Equal Opportunity Employer/Vet/Disability

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