Payment Integrity Program Specialist

Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

• Coordinate day-to-day activities with external payment integrity vendors and business partners.
• Coordinate and support implementation of new payment integrity initiatives, audit programs, recovery projects, and operational enhancements.
• Track and monitor vendor performance metrics, service level agreements, recoveries, savings, and project milestones.
• Assist with maintenance of payment integrity inventories, project plans, work logs, and tracking tools.
• Coordinate internal and external meetings, document action items, and monitor follow-up activities.
• Prepare reports, presentations, and supporting documentation for leadership, committees, and business partners.
• Support regulatory reporting, audit requests, and documentation requirements.
• Maintain payment integrity policies, procedures, workflows, and program documentation.
• Facilitate communication between Payment Integrity, Claims, Finance, Compliance, Provider Relations, Information Technology, and external vendors.
• Assist with implementation testing, operational readiness activities, and post-implementation monitoring.
• Support process improvement initiatives and departmental projects.
• Monitor project risks, issues, and dependencies and escalate concerns to leadership as appropriate.
• Assist with tracking recoveries, cost avoidance activities, vendor savings, and operational performance metrics.
• Participate in departmental meetings and represent Payment Integrity on assigned projects and workgroups.
• Assist with contract, statement of work, and vendor performance document management.

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Work Experience: Minimum of 3 years of healthcare operations, project coordination, vendor management, claims administration, payment integrity, or closely related experience required.

Education, Certificates, Licenses: Bachelor's degree preferred. High school diploma or equivalent required

Knowledge: Healthcare operations and claims administration. Project coordination and implementation support. Vendor management and performance monitoring. Reporting and documentation management. Microsoft Excel, PowerPoint, and other business productivity tools. Healthcare reimbursement and payment integrity concepts preferred.

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.

• We are one team working toward a common goal.

• We are each responsible for customer service.

• We practice open communication at all levels of the company to foster individual, team and company growth.

• We actively participate in efforts to improve our many communities-internally and externally.

• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

Originally posted on Himalayas