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Job Summary:
Essential Responsibilities
Payment Integrity Operations
Oversee monitoring, analysis, and reporting of claims activity (e.g., trends, outliers, high-cost claims, line-of-business segmentation).
Manage development and maintenance of tracking mechanisms, dashboards, and documentation related to audits, findings, and overpayment recoveries.
Ensure accurate invoicing and reconciliation for programs and vendors; oversee processing of recoupments and refunds.
Identify root causes of overpayments, track trends, and drive corrective actions with accountable owners.
Define and execute the enterprise payment integrity and coding audit strategy; align program goals with CareOregon's mission, vision, values, and strategic plan.
Build business cases and ROI models to expand initiatives, resources, and technology enabling sustainable savings and improved accuracy.
Establish governance, KPIs, and reporting cadence for program performance, savings, recoveries, and risk mitigation.
Coding Audit & Education
Lead a portfolio of coding audits (prospective and retrospective), ensuring accurate capture of diagnosis and procedure codes in claims and chart review data.
Serve as subject matter expert for ICD-10-CM/PCS, CPT/HCPCS, and associated coding conventions; actively maintain and enforce AMA/CMS guidelines.
Lead Risk Adjustment Data Validation (RADV) and related diagnosis code audits (for Finance/Risk Adjustment as applicable).
Develop and deliver training and education for providers and internal stakeholders (e.g., recorded modules, reference guides, job aids).
Create and maintain centralized policy, process, compliance documentation, and SOPs related to coding and risk adjustment.
Quality and User Acceptance Testing
Manage a team of quality auditors responsible for testing the accuracy of transactional processing.
Track, trend and report on quality audit results on a weekly, monthly, quarterly and year-to-date basis.
Develop or expand performance metrics to assess the quality of our payments and their improvement over time.
Identify and recommend changes/enhancements to processes, processing guides and/or internal tools to achieve improved quality outcomes.
Develop, manage and schedule Operations user acceptance testing, scripting, playbooks and job aides.
Process Improvement & Analytics
CareOregon is an equal opportunity employer.& #8239; The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.
Job Classification:
Accountants and Auditors Access our statewide or regional occupation report for more information about wages,
employment outlooks, skills, training programs, related occupations, and more. Compensation
Salary:
$90,225.00 to $110,275.00 per Year Job Requirements
