Senior Manager, Payment Integrity- Provider Experience & Enablement

📋 Description

• • Lead the strategic direction and operational execution of the Health Plan Concierge function, serving as the primary point of contact for escalated provider issues within Payment Integrity.
• • Drive a proactive and collaborative approach to managing provider impacts of Payment Integrity programs, ensuring alignment and clear communication across internal teams and external stakeholders.
• • Act as a critical liaison between Payment Integrity, Network, Health Plans, Claims, and other cross-functional departments to foster a unified understanding of provider concerns and program implications.
• • Oversee the end-to-end resolution of complex provider escalations that fall outside standard dispute processes, ensuring accuracy, transparency, and a balanced consideration of provider experience and enterprise objectives.
• • Develop and implement strategies to enhance the provider experience by identifying and mitigating friction points within Payment Integrity processes.
• • Champion provider enablement through the creation and dissemination of clear, accessible, and data-driven educational materials, training programs, and communication resources.
• • Establish and maintain consistent messaging standards for Payment Integrity programs, empowering partner teams to drive uniform understanding across the provider network.
• • Analyze provider feedback, escalation themes, and trend data to generate actionable insights that inform program enhancements, process improvements, and strategic decision-making.
• • Lead and facilitate cross-functional triage meetings for complex provider concerns, ensuring aligned decision pathways, consistent internal messaging, and a unified resolution experience.
• • Oversee the development, organization, and quality assurance of defensible case documentation to support pre-litigation reviews, arbitration preparation, and in-depth provider issue assessments, ensuring accuracy, completeness, and audit readiness.
• • Evaluate and optimize Payment Integrity processes and related workflows across collaborating functions to streamline operations, improve the provider experience, enhance cost avoidance, and strengthen financial recovery performance.
• • Drive continuous improvement initiatives and implement scalable solutions to address systemic issues and enhance operational efficiency.
• • Prepare, interpret, and present comprehensive reports and insights to senior leadership, focusing on provider experience trends, escalation patterns, cost avoidance, recovery outcomes, and operational impacts.
• • Provide data-driven recommendations to inform strategic decisions and shape enterprise-level Payment Integrity initiatives.
• • Collaborate closely with Network and Health Plan teams to ensure Payment Integrity programs are operationally ready and consider downstream provider impacts and contracting implications.
• • Influence decision-making by proactively identifying potential provider impacts and recommending necessary adjustments to program design or implementation.
• • Ensure compliance with all company policies, standards, and regulatory requirements.
• • Manage direct reports, fostering a high-performing team environment focused on service excellence and strategic impact.
• • Stay abreast of industry best practices and emerging trends in payment integrity, provider relations, and healthcare operations.
• • Contribute to the development of departmental goals and objectives, aligning them with the broader organizational strategy.
• • Foster a culture of continuous learning and development within the team, encouraging professional growth and skill enhancement.
• • Represent the Payment Integrity department in cross-functional forums and meetings as needed.
• • Ensure that all provider interactions are conducted with professionalism, empathy, and a commitment to fair resolution.
• • Develop and maintain strong working relationships with key internal and external stakeholders, including provider organizations and industry associations.
• • Contribute to the development and refinement of policies and procedures related to payment integrity and provider engagement.
• • Monitor key performance indicators (KPIs) related to provider escalations, resolution times, and satisfaction, implementing corrective actions as needed.
• • Drive the adoption of new technologies and tools that can enhance the efficiency and effectiveness of payment integrity operations and provider engagement.
• • Ensure the integrity and accuracy of data used for reporting and analysis related to provider experience and payment integrity outcomes.
• • Proactively identify opportunities for process automation and efficiency gains within the provider experience and enablement functions.
• • Support the development of business cases for new initiatives or process improvements, quantifying potential benefits and resource requirements.
• • Act as a subject matter expert on provider experience and enablement within the Payment Integrity domain.
• • Ensure that all communication and documentation adheres to legal and regulatory guidelines.
• • Contribute to a positive and collaborative work environment, promoting teamwork and mutual respect.