Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Senior Manager of Payment Payment Integrity is responsible for managing the review and validation of Medicare Advantage provider claims and payments prior to payment. This position focuses on ensuring the accuracy of claims, preventing fraud, waste, and abuse, and maintaining compliance with CMS regulations, provider contracts, and company policies. The Senior Manager will oversee pre-payment workflows, including clinical validation, itemized bill reviews, claim editing software utilization, and auditing activities, to ensure payment accuracy and protect the financial integrity of the organization.

Job Duties/Responsibilities: ·

1. Lead the pre-payment review process, ensuring all Medicare Advantage claims are accurate, complete, and compliant with regulatory and contractual guidelines before payment is issued.

2. Conduct detailed itemized bill reviews to ensure all billed services are medically necessary, appropriately coded, and aligned with provider contracts and CMS regulations.

3. Use claim editing software (e.g., Truven, 3M, Optum) to detect and prevent payment errors, ensuring claims edits align with CMS guidelines and internal policies.

4. Actively monitor claims and payment data to identify and prevent fraud, waste, and abuse within the payment process. Collaborate with compliance and audit teams to detect suspicious patterns or activities.

5. Review and ensure that all claims comply with the terms out-lined in provider contracts, including reimbursement rates, service types, and any contract-specific rules.

6. Oversee workflows related to clinical validation to ensure that the medical necessity and appropriateness of services are properly documented and validated in claims prior to payment. Collaborate with clinical teams to resolve any discrepancies in clinical data.

7. Identify potential payment discrepancies and trends, utilizing data-driven insights to implement strategies for reducing improper payments.

8. Work closely with cross-functional teams such as Claims, Provider Relations, Compliance, Clinical Operations, and Finance to ensure seamless communication and alignment in payment integrity processes.

9. Develop and present comprehensive reports on audit results, performance metrics, and emerging trends. Provide actionable insights to enhance payment accuracy and operational efficiency.

10. Lead initiatives to improve the pre-payment review process, streamline workflows, and enhance clinical validation protocols, with the goal of reducing administrative burden and increasing payment accuracy.

11. Investigate payment discrepancies, fraud indicators, or compliance issues, conducting root cause analysis to identify underlying causes and recommend corrective actions.

12. Identify potential risks related to fraud, waste, abuse, and payment errors, and implement strategies to mitigate financial risks and improve compliance.

Supervisory Responsibilities:

Oversees assigned staff. Responsibilities include: recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.

Job Requirements:

Experience:

Required: Minimum of 5-7 years of experience in healthcare payment integrity, claims auditing, fraud detection, or similar roles, with at least 3 years in a leadership position.

In-depth understanding of CMS regulations, Medicare Advantage claims processing, clinical validation work-flows, fraud, waste, and abuse prevention, and pre-payment review practices.

Education:

Required: High School Diploma or GED. Bachelors degree or four years additional experience in lieu of education.

Training:

Required: None

Preferred: CPC (Certified Professional Coder), CRC (Certified Revenue Cycle), or other related certifications

Specialized Skills:

Required:

o Leadership and team management abilities

o Strong analytical, problem-solving, and data-driven decision-making skills

o Expertise in claim editing software (e.g., Optum, 3M, Cotiviti)

o Strong understanding of clinical validation, medical necessity, and payment accuracy

o Excellent communication, organizational, and interpersonal skills

o Ability to manage multiple priorities in a fast-paced environment

o High attention to detail and accuracy o Experience in Medicare Advantage or health plan environments

Preferred:

o Familiarity with claims management systems such as Facets, QNXT, or similar platforms.

o Expertise in auditing itemized medical bills and ensuring compliance with provider contracts and CMS guidelines.

o Leadership and team management abilities Strong knowledge of healthcare coding (ICD-10, CPT, HCPCS) and regulatory compliance.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $98,550.00 - $147,825.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.