Qureos Mentor

CareOregon

<div>Payment Integrity Coding Manager
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The Payment Integrity Coding Manager is responsible for developing, implementing, and continuously improving enterprise-wide payment integrity and claims programs and strategies to ensure that CareOregon&rsquo;s claims editing, coding compliance, provider education, audit and recovery, and quality assurance, align with organizational goals and compliance with American Medical Association (AMA), Centers for Medicare &amp; Medicaid Services (CMS), and state regulatory requirements. The position requires effective alignment and integration with multiple internal and external teams and stakeholders including, but not limited to, coordination between vendors, legal, audit, compliance, finance, data analytics and network operational functions.
 
 
The Manager partners closely with internal and external stakeholders&mdash;including vendors, Legal, Audit, Compliance, Finance, Data Analytics, Network Operations, Provider Relations, and Clinical Operations&mdash;to drive accurate payments, mitigate risk, and optimize recoveries. The role also oversees user acceptance testing (UAT) for system changes impacting claims and coding and develops business cases to scale payment integrity initiatives.`q1saw
Estimated Hiring Range:
$92,070.00 - $112,530.00
Bonus Target:
Bonus - SIP Target, 5% Annual
Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.
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Essential Responsibilities
Payment Integrity Operations<ul><li>
Oversee monitoring, analysis, and reporting of claims activity (e.g., trends, outliers, high-cost claims, line-of-business segmentation).</li><li>
Manage development and maintenance of tracking mechanisms, dashboards, and documentation related to audits, findings, and overpayment recoveries.</li><li>
Ensure accurate invoicing and reconciliation for programs and vendors; oversee processing of recoupments and refunds.</li><li>
Identify root causes of overpayments, track trends, and drive corrective actions with accountable owners.</li><li>
Define and execute the enterprise payment integrity and coding audit strategy; align program goals with CareOregon&rsquo;s mission, vision, values, and strategic plan.</li><li>
Build business cases and ROI models to expand initiatives, resources, and technology enabling sustainable savings and improved accuracy.</li><li>
Establish governance, KPIs, and reporting cadence for program performance, savings, recoveries, and risk mitigation.</li></ul>
Coding Audit &amp; Education<ul><li>
Lead a portfolio of coding audits (prospective and retrospective), ensuring accurate capture of diagnosis and procedure codes in claims and chart review data.</li><li>
Serve as subject matter expert for ICD-10-CM/PCS, CPT/HCPCS, and associated coding conventions; actively maintain and enforce AMA/CMS guidelines.</li><li>
Lead Risk Adjustment Data Validation (RADV) and related diagnosis code audits (for Finance/Risk Adjustment as applicable).</li><li>
Develop and deliver training and education for providers and internal stakeholders (e.g., recorded modules, reference guides, job aids).</li><li>
Create and maintain centralized policy, process, compliance documentation, and SOPs related to coding and risk adjustment.</li></ul>
Quality and User Acceptance Testing<ul><li>
Manage a team of quality auditors responsible for testing the accuracy of transactional processing.</li><li>
Track, trend and report on quality audit results on a weekly, monthly, quarterly and year-to-date basis.</li><li>
Develop or expand performance metrics to assess the quality of our payments and their improvement over time.</li><li>
Identify and recommend changes/enhancements to processes, processing guides and/or internal tools to achieve improved quality outcomes.</li><li>
Develop, manage and schedule Operations user acceptance testing, scripting, playbooks and job aides.</li></ul>
Process Improvement &amp; Analytics<ul><li>
Work with CareOregon departments to develop and oversee standard operating procedures to ensure that consistent business rules are applied in claim adjudication.</li><li>
Review claims, hospital bills, and physician notes and data to devise and refine procedures for identifying billing errors and resolving problematic provider billing practices.</li><li>
Work with the Provider Relations team and the Audit and Compliance team to develop ongoing processes for auditing provider bills, recording errors and tracking collections.</li><li>
Work closely with data analysts, clinical operations, technical, legal and operational teams to create sustainable and scalable cost savings solutions.</li><li>
Use data analytics to find new opportunities to expand the scope of payments reviewed.</li><li>
Perform variance analysis, assist with medical claims reconciliation and payment process development/improvement.</li><li>
Align with fraud waste and abuse reduction initiatives and lead resultant initiatives and projects.</li><li>
Develop and maintain department&rsquo;s policies, procedures and workflows.</li><li>
Develop training documents and conduct process trainings on a regular basis.</li><li>
Identify opportunities for improvement and recommend solutions.</li></ul>
Employee Supervision<ul><li>
Manage team and recommend team direction and goals in alignment with the organizational mission, vision, and values.</li><li>
Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.</li><li>
Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.</li><li>
Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.</li><li>
Train, supervise, motivate, and coach employees; provide support toward employee development.</li><li>
Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.</li><li>
Ensure team adheres to department and organizational standards, policies, and procedures.</li><li>
Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).</li><li>
Perform supervisory tasks in collaboration with Human Resources as needed.</li></ul>
Organizational Responsibilities<ul><li>
Perform work in alignment with the organization&rsquo;s mission, vision and values.</li><li>
Support the organization&rsquo;s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.</li><li>
Strive to meet annual business goals in support of the organization&rsquo;s strategic goals.</li><li>
Adhere to the organization&rsquo;s policies, procedures and other relevant compliance needs.</li><li>
Perform other duties as needed.</li></ul>
Experience and/or Education
Required
Minimum 5 years&rsquo; management experience in health plan claims operations, audit, and/or payment integrity.
Minimum 5 years&rsquo; experience as a certified coder and/or Certified Coding auditor with active certification AHIMA or AAPC (e.g., CPC, CCS, CCA, CMC or equivalent).
Preferred<ul><li>
Experience performing statistical claims analysis in a managed care or health care setting.
Experience in and/or understanding of payment integrity programs and vendors.
Experience with SQL Server Reporting, or using business intelligence tools (e.g., Tableau) and data framework.</li></ul><h3 class="jobSectionHeader">
Knowledge, Skills and Abilities Required</h3>
Knowledge<ul><li>
Strong understanding of state and federal regulations that impact operations in order to properly respond</li><li>
Knowledge of how to confidently navigate through complex and challenging business issues</li><li>
Working knowledge of different claims coding requirements and payment methodologies (e.g., PPS, Medicare fee schedules, etc.)</li><li>
Knowledge of medical terminology</li><li>
Knowledge and skill in claims system management, editing software, and coding</li></ul>
Skills and Abilities<ul><li>
Strong detail-orientation skills</li><li>
Strong project management skills</li><li>
Adept at prioritizing work</li><li>
Ability to develop payment processes and solutions for low income, Medicaid, and Medicare populations</li><li>
Comprehensive program development, management and evaluation skills</li><li>
Statistical, analytical, problem-solving and organizational skills</li><li>
Excellent spoken, written and presentation communication skills</li><li>
Ability to use computer programs commonly used for health plan operations</li><li>
Ability to lead and influence change and results</li><li>
Skill in negotiation and ability to build consensus</li><li>
Skill in leading people, including the ability to coach and mentor staff</li><li>
Excellent interpersonal skills</li><li>
Ability to maintain professional relationships with internal and external staff and departments</li><li>
Ability to present a positive and professional image as a leader and representative of CareOregon</li><li>
Ability to work well under pressure in a complex and rapidly changing environment</li><li>
Ability to support and comply with organizational policies, procedures and guidelines</li><li>
Ability to work effectively with diverse individuals and groups</li></ul><ul><li>
Ability to learn, focus, understand, and evaluate information and determine appropriate actions</li><li>
Ability to accept direction and feedback, as well as tolerate and manage stress</li><li>
Ability to see, read, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/day</li></ul>
Working Conditions
Work Environment(s): Indoor/Office Community Facilities/Security Outdoor Exposure
Member/Patient Facing: No Telephonic In Person
Hazards: May include, but not limited to, physical and ergonomic hazards.
Equipment: General office equipment
Travel: May include occasional required or optional travel outside of the workplace; the employee&rsquo;s personal vehicle, local transit or other means of transportation may be used.
Work Location: Work from home
We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&amp;D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.
We are an equal opportunity employer
CareOregon is an equal opportunity employer. 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.</div>

Payment Integrity Coding Manager

<div>Nurse Practitioner / NP - Primary Care - Hourly
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This position provides medical care and treatment services with emphasis on chronic disease management and promotion of health and palliative care for patients not best served in a clinic setting. Care is provided in patient residencies, as well through audio and video sessions. This position may focus on one of the following areas: 
 
New Patient intake: Provides initial comprehensive assessment management and on-boarding of new patients to the clinic. 
Relief Care: Provides post hospital visits or urgent care visits for change in condition and supports change in the plan of care where needed. Provides relief and/or urgent care for patients on a short-term basis, focusing on filling in for providers who are out of the office. 
NOTE: This is a 16 hr/wk (0.4 FTE) position.
Estimated Hiring Range:
$66.42 - $81.18
Bonus Target:
Bonus - SIP Target, 5% Annual
Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.
-<h2 class="jobSectionHeader">
Essential Responsibilities</h2>
Clinical Service<ul><li>
Provide diagnosis, treatment, consultation, and follow-up care of patients in collaboration with patient assigned PCP including diagnosis and treatment of critical, prolonged, and long-term healthcare issues.</li><li>
Perform comprehensive health assessment of clients by completing a physical and psychosocial history; identify actual and potential health needs based on medical, mental/emotional, financial, and social factors.</li><li>
Make referrals to appropriate social or medical agencies and practitioners.</li><li>
Identify, evaluate, and address the prevention of diseases, maintenance of chronic diseases, and appropriate end-of-life care per the goals of care outlined by the patient and their families.</li><li>
Develop and implement proactive patient centered care plan with the assistance of other disciplines within the care team.</li><li>
Order testing in diagnostics, orders medications with appropriate follow up and reassessment, and performs some surgical procedures as appropriate under certification.</li><li>
Approve medication refills and home health orders and respond to caregiver requests to provide continuity of care.</li><li>
Provide compassionate anticipatory guidance through decline due to chronic disease and provide high quality palliative care focused on the goals of the patient and family.</li><li>
Educate patients and families on goal-based, appropriate preventative care, medical issues, and use of prescribed medications and treatment.</li><li>
Develop and maintain relationships with lay and professional caregivers, including care facilities, to assure patient experience excellent continuity of care and orders are implemented appropriately.</li><li>
Educate patients and families on their preventive care, medical issues, and use of prescribed medications and treatment.</li><li>
Deliver quality care while maintaining all company metrics pertaining to productivity.</li><li>
Practice within the scope of license where applicable, and as required by law and regulation.</li><li>
May participate in the after-hours call schedule.</li></ul>
Administration<ul><li>
Communicate effectively with members of the medical staff on issues concerning consultation, collaboration, and referrals.</li><li>
Educate patients and families on their preventive care, medical issues, and use of prescribed medications and treatment.</li><li>
Determine need for specialty and rehabilitative services and make appropriate referrals.</li><li>
Attend and participate in all required staff meetings and other ad hoc committees as assigned.</li><li>
Provide coverage for clinical colleagues in their absence.</li><li>
Participate in quality improvement activities as assigned.</li><li>
Complete and maintains medical records according to agency protocols and in support of quality metrics. Document new patient history and physical to appropriate coding standards and quality metrics.</li></ul><h2 class="jobSectionHeader">
Organizational Responsibilities</h2><ul><li>
Perform work in alignment with the organization&rsquo;s mission, vision and values.</li><li>
Support the organization&rsquo;s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.</li><li>
Strive to meet annual business goals in support of the organization&rsquo;s strategic goals.</li><li>
Adhere to the organization&rsquo;s policies, procedures and other relevant compliance needs.</li><li>
Perform other duties as needed.</li></ul>
Experience and/or Education
Required<ul><li>
Master&rsquo;s degree from an accredited advanced nurse practitioner program</li><li>
Licensed nurse practitioner in the state of Oregon (ANCC or AANP certified)</li><li>
Drug Enforcement Administration (DEA) license</li><li>
Valid driver&rsquo;s license, acceptable driving record, and automobile liability coverage or access to an insured vehicle</li><li>
CPR certification at hire or within 6 months in position</li></ul>
Preferred<ul><li>
Minimum 2 years of related clinical experience</li></ul><h3 class="jobSectionHeader">
Knowledge, Skills and Abilities Required</h3>
Knowledge<ul><li>
Knowledge of the principles and practice of medicine especially</li><li>
Knowledge of principles, practices and procedures of general medicine</li><li>
Knowledge of methods and techniques of diagnosing and treating a variety of diseases and injuries</li><li>
Knowledge of sources of information and current literature applicable to the field of general medicine</li><li>
Knowledge of the ethical and medico-legal aspects of medical practice</li><li>
Knowledge of the principles and practices of public health, including familiarity with epidemiology, health services delivery and financing systems, and environmental health</li><li>
Knowledge of the population served in adult health, including culture, demographics, patterns of disease, barriers to care and other unique features or special needs</li><li>
Knowledge of the principles and practices of clinical quality improvement</li></ul>
Skills and Abilities<ul><li>
Proficient in the practice of geriatrics and palliative care</li><li>
Skill in utilizing electronic systems appropriately and effectively, including audio and video supported encounters</li><li>
Ability to perform medical diagnostic and treatment services</li><li>
Ability to establish and maintain effective working relationships with diverse patients, staff, peer groups, and varied agency and institutional representatives</li><li>
Ability to deal professionally and calmly with individuals that may act inappropriately, be verbally abusive, hostile and/or in crisis</li><li>
Ability to communicate clearly, compassionately, and concisely, both verbally and in writing</li><li>
Cultural competence and ability to work effectively with people from all walks of life</li><li>
Compassion, commitment, and integrity required for success in this position</li><li>
Ability to work within a team and take direction from other team members with expertise in the care plan development</li><li>
Ability to adhere to organizational standards, policies, procedures.</li><li>
Ability to work effectively with diverse individuals and groups</li></ul><ul><li>
Ability to learn, focus, understand, and evaluate information and determine appropriate actions</li><li>
Ability to accept direction and feedback, as well as tolerate and manage stress and grief</li><li>
Ability to see, read, hear, speak clearly, sit and perform repetitive finger and wrist movement for at least 6 hours/day</li></ul><ul><li>
Ability to stand, climb stairs, bend, lift, carry, push, pull and/or pinch small objects for at least 3-6 hours/day</li><li>
Ability to walk, crouch, crawl and reach for at least 3 hours/day</li><li>
Ability to operate a motorized vehicle in all kinds of weather conditions</li></ul>
Working Conditions
Work Environment(s): Indoor/Office Community Facilities/Security Outdoor Exposure
Member/Patient Facing: No Telephonic In Person
Hazards: May include, but not limited to, physical, ergonomic, and biological hazards
Equipment: General office equipment and/or mobile technology
Travel: This position requires travel outside of the workplace at least weekly; the employee&rsquo;s personal vehicle may be used. Driving infractions will be monitored in accordance with organizational policy.
Work Location: Hybrid-Community 2 days/week, member facing
Location: Employees permanently assigned to see members and patients in Marion or Polk counties are required to live within 15 miles of their county assignment.
Schedule: Work a flexible schedule, including evenings and weekends.
If you receive an offer of employment for this position, it is contingent on the satisfactory completion of a pre-employment background check, immunization review, and drug screen (including THC/Marijuana). CareOregon is a federal contractor and must comply with all federal laws.
We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. Housecall Providers offers medical, dental, vision, life, AD&amp;D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.
We are an equal opportunity employer
Housecall Providers is an equal opportunity employer. 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.</div>

Nurse Practitioner / NP - Primary Care - Hourly

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Payment Integrity Coding Manager

Nurse Practitioner / NP - Primary Care - Hourly