Exec Dir, Payment Integrity & AIS Medical Expense Solutions

Job Summary:

The position is responsible for establishing and leading the National Payment Integrity Solutions shared service programs. To include:

Leading and managing National Claims Cost Containment/Payment Integrity programs, operations projects and initiatives to include (but not limited to) the following functional areas: COB/TPL/Work Comp cost avoidance and recovery; Code Editing technology strategy and rules management; Pre & Post Payment Audit/Claim review (including Clinical/Medical Audit); Internal and Vendor supported overpayment identification and Recovery processes (Collections, Credit Offset, Adjustment & Cash Posting); Data management and Decision Support reporting/analytic capabilities supporting both the Cost Containment/Payment Integrity functions as well as Regional/National leadership and financial planning functions; Operational Technology infrastructure and tools. Directing strategic planning for Cost Containment/Payment Integrity capability insuring alignment with National & Regional Claims strategy.

Essential Responsibilities:

• National Payment Integrity
• Develop, lead, operate and manage National Claims Cost Containment/Payment Integrity programs, operations projects and initiatives with objective of achieving claims payment cost avoidance and recovery targets.
• Develop, lead, operate and manage National Claims Pre & Post Payment Audit/Claim review (including Clinical/Medical Audit) programs, operations projects and initiatives with objective of achieving claims payment cost avoidance and recovery targets.
• Ensure that Kaiser Permanente (KP) is positioned to maintain ongoing regulatory compliance with respect to Payment Integrity processes across the continuum, including maintenance of the CMS, State Commercial and Medicaid standards of performance.
• Provide leadership and guidance to Payment Integrity operational functions on reporting, workforce planning & management, data visualizations & performance management dashboards.
• Partner/Collaborate with National Compliance on related Fraud & Abuse detection programs.
• Oversee the development and maintenance of key operational relationships for the achievement of quality outcomes for Claims Cost Containment / Payment Integrity.
• Lead programs to achieve continuous improvement in process standardization and performance.
• Build and maintain responsive, motivated and efficient departments to ensure results orientation.
• Partner with other KFHP/H and PMG executives to ensure leveraging of capabilities and sharing of best practices in Payment Integrity services. Communicate and provide visibility regarding NCA claim payment policies and processes
• Engage with markets and provide excellent customer service to our market partners and external provider network ensuring an overall positive experience. Includes the active engagement at leadership meetings conducted by the Market Leadership to solve issues with the external provider network associated with NCA claim payment policies contract disputes and NPI programs. Develop strong collaboration to ensure superior service is provided to our members and providers.
• Communicate results and progress to both technical and non-technical audiences effectively, including presenting to senior executives, industry conferences, technical seminars, or meet-ups.
• Negotiate and manage strategic vendor programs supporting advanced Payment Integrity solutions to deliver substantial new medical expense savings opportunities.
• Research industry trends and advancements in analytics and technology to ensure the latest systems, processes and tools are being leveraged for advancing claims Payment Integrity and related medical expense controls.
• Manage and coach a team of senior level employees including directors, program managers, and technical staff.