{"schemaVersion":"jobsearcher.job.v1","id":"d5ce4c7c101b976d5434d06f","url":"https://jobsearcher.com/jobs/d5ce4c7c101b976d5434d06f","canonicalUrl":"https://jobsearcher.com/jobs/d5ce4c7c101b976d5434d06f","title":"Manager, Payment Integrity","description":"Looking for a way to make an impact and help people?\r\nJoin PacificSource and help our members access quality, affordable care!\r\nPacificSource 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.\r\nThe Manager of Payment Integrity (PI) leads the strategic design, implementation, and execution of programs aimed at improving payment accuracy and enhancing member affordability. This role serves as a key liaison for reimbursement policy and PI initiatives, ensuring alignment between cost-of-care objectives and departmental priorities through structured governance, ideation, and business case development. The Manager oversees program-level performance tracking to ensure measurable impact and continuous improvement. In close collaboration with Health Care and Finance divisions, this role supports enterprise-wide cost-of-care strategies by identifying operational efficiencies, uncovering savings opportunities, and fostering innovative partnerships that expand the reach and effectiveness of PI initiatives.\r\nEssential Responsibilities\r\n\r\nLeads the development and execution of enterprise-wide Payment Integrity strategies aligned with financial and operational goals.\r\nOversees a comprehensive suite of pre- and post-payment programs-including claims editing, audits, subrogation, readmission reviews, and coordination of benefits-while continuously refining approaches to address evolving trends such as value-based care, regulatory shifts, and emerging fraud schemes.\r\nManages external vendors supporting audits, analytics, and fraud detection. Ensures accountability through robust service-level agreements (SLAs), key performance indicators (KPIs), and contract negotiations. Monitors and reports on recovery rates, audit turnaround times, and dispute resolution outcomes.\r\nDirects Fraud Waste and Abuse (FWA) detection efforts in collaboration with Special Investigations Unit (SIU) and compliance teams. Leverages predictive analytics and rules engines to identify suspicious billing patterns, ensuring timely investigation, documentation, and resolution.\r\nEnsures compliance with ICD-10, CPT/HCPCS, DRG, and CMS guidelines to support accurate coding and reimbursement. Serves as a subject matter expert on complex coding issues and documentation standards, providing training and oversight to internal teams and vendors.\r\nIntegrates Payment Integrity efforts with care quality initiatives, targeting avoidable readmissions and preventable complications. Maintains compliance with CMS, Medicaid, ACA, and state-specific regulations. Leads audit responses and represents the organization in national forums such as AHIP, AAPC, HPRI, NHCAA, New York State DFS, DOH, and HPA.\r\nChampions the adoption of Artificial Intelligence (AI), machine learning, and automation in audit workflows and fraud detection. Pilots emerging technologies and integrates them into core operations. Collaborates with IT and analytics teams to enhance data infrastructure and reporting capabilities.\r\nPartners across Claims Operations, Finance, Provider Relations, Compliance, IT, and Care Management to embed Payment Integrity throughout the organization. Translates complex technical concepts into actionable insights for diverse stakeholders.\r\nResponsible for oversight, management, development, implementation, and communication of department programs.\r\nResponsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.\r\nDevelop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.\r\nCoordinate business activities by maintaining collaborative partnerships with key departments.\r\nResponsible for process improvement and working with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.\r\nActively participate as a key team member in Manager/Supervisor meetings.\r\nActively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.\r\n\r\nSupporting Responsibilities\r\n\r\nMeet department and company performance and attendance expectations.\r\nFollow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.\r\nPerform other duties as assigned.\r\n\r\nSUCCESS PROFILE\r\nWork Experience: A minimum of 5 years of progressive experience in healthcare operations. Expertise in claims processing, clinical coding, reimbursement strategies, and/or fraud prevention required. Demonstrated success in strategic planning, vendor oversight, and cross-functional collaboration to drive operational excellence and cost containment required.\r\nEducation, Certificates, Licenses: Bachelor's degree required. Candidates with an associate's degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of Work Experience will also be considered Preferred area of focus: Healthcare Operations, Statistics, or a related field.\r\nKnowledge: Proven track record of leading operational initiatives from concept through execution, with a focus on provider reimbursement and claims payment integrity. Deep expertise in managed care claims coding, including CPT, ICD, HCPCS, Revenue Codes, and comprehensive understanding of federal and state Medicaid payment regulations. Proficient in Excel and SQL, leveraging data analysis to drive informed business decisions without reliance on technical support.\r\nCompetencies\r\nBuilding Trust\r\nBuilding a Successful Team\r\nAligning Performance for Success\r\nBuilding Partnerships\r\nCustomer Focus\r\nContinuous Improvement\r\nDecision Making\r\nFacilitating Change\r\nLeveraging Diversity\r\nDriving for Results\r\nEnvironment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.\r\nSkills\r\nAccountable leadership, Collaboration, Data-driven & Analytical, Delegation, Effective communication, Listening (active), Situational Leadership, Strategic Thinking\r\nCompensation Disclaimer\r\nThe 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.\r\nBase Range\r\n$90,052.16 - $157,591.26\r\nOur Values\r\nWe live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:\r\n\r\n\r\nWe are committed to doing the right thing.\r\n\r\n\r\nWe are one team working toward a common goal.\r\n\r\n\r\nWe are each responsible for customer service.\r\n\r\n\r\nWe practice open communication at all levels of the company to foster individual, team and company growth.\r\n\r\n\r\nWe actively participate in efforts to improve our many communities-internally and externally.\r\n\r\n\r\nWe actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.\r\n\r\n\r\nWe encourage creativity, innovation, and the pursuit of excellence.\r\n\r\n\r\nPhysical 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.\r\nDisclaimer: 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.","company":"Pacificsource","rawCompany":"pacificsource","city":"Boise","state":"ID","isRemote":false,"isActive":false,"createdAt":"2026-04-21T04:29:55.337Z","occupations":[{"code":"11-9111.00","title":"Medical and Health Services Managers","slug":"medical-and-health-services-managers"},{"code":"11-9199.02","title":"Compliance Managers","slug":"compliance-managers"},{"code":"11-1021.00","title":"General and Operations Managers","slug":"general-and-operations-managers"}],"industries":[{"code":"522320","title":"Financial Transactions Processing, Reserve, and Clearinghouse Activities","slug":"financial-transactions-processing-reserve-and-clearinghouse-activities"},{"code":"524292","title":"Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds","slug":"pharmacy-benefit-management-and-other-third-party-administration-of-insurance-and-pension-funds"},{"code":"524114","title":"Direct Health and Medical Insurance Carriers","slug":"direct-health-and-medical-insurance-carriers"}],"jobPosting":{"@context":"https://schema.org","@type":"JobPosting","title":"Manager, Payment Integrity","description":"Looking for a way to make an impact and help people?\r\nJoin PacificSource and help our members access quality, affordable care!\r\nPacificSource 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.\r\nThe Manager of Payment Integrity (PI) leads the strategic design, implementation, and execution of programs aimed at improving payment accuracy and enhancing member affordability. This role serves as a key liaison for reimbursement policy and PI initiatives, ensuring alignment between cost-of-care objectives and departmental priorities through structured governance, ideation, and business case development. The Manager oversees program-level performance tracking to ensure measurable impact and continuous improvement. In close collaboration with Health Care and Finance divisions, this role supports enterprise-wide cost-of-care strategies by identifying operational efficiencies, uncovering savings opportunities, and fostering innovative partnerships that expand the reach and effectiveness of PI initiatives.\r\nEssential Responsibilities\r\n\r\nLeads the development and execution of enterprise-wide Payment Integrity strategies aligned with financial and operational goals.\r\nOversees a comprehensive suite of pre- and post-payment programs-including claims editing, audits, subrogation, readmission reviews, and coordination of benefits-while continuously refining approaches to address evolving trends such as value-based care, regulatory shifts, and emerging fraud schemes.\r\nManages external vendors supporting audits, analytics, and fraud detection. Ensures accountability through robust service-level agreements (SLAs), key performance indicators (KPIs), and contract negotiations. Monitors and reports on recovery rates, audit turnaround times, and dispute resolution outcomes.\r\nDirects Fraud Waste and Abuse (FWA) detection efforts in collaboration with Special Investigations Unit (SIU) and compliance teams. Leverages predictive analytics and rules engines to identify suspicious billing patterns, ensuring timely investigation, documentation, and resolution.\r\nEnsures compliance with ICD-10, CPT/HCPCS, DRG, and CMS guidelines to support accurate coding and reimbursement. Serves as a subject matter expert on complex coding issues and documentation standards, providing training and oversight to internal teams and vendors.\r\nIntegrates Payment Integrity efforts with care quality initiatives, targeting avoidable readmissions and preventable complications. Maintains compliance with CMS, Medicaid, ACA, and state-specific regulations. Leads audit responses and represents the organization in national forums such as AHIP, AAPC, HPRI, NHCAA, New York State DFS, DOH, and HPA.\r\nChampions the adoption of Artificial Intelligence (AI), machine learning, and automation in audit workflows and fraud detection. Pilots emerging technologies and integrates them into core operations. Collaborates with IT and analytics teams to enhance data infrastructure and reporting capabilities.\r\nPartners across Claims Operations, Finance, Provider Relations, Compliance, IT, and Care Management to embed Payment Integrity throughout the organization. Translates complex technical concepts into actionable insights for diverse stakeholders.\r\nResponsible for oversight, management, development, implementation, and communication of department programs.\r\nResponsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.\r\nDevelop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.\r\nCoordinate business activities by maintaining collaborative partnerships with key departments.\r\nResponsible for process improvement and working with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.\r\nActively participate as a key team member in Manager/Supervisor meetings.\r\nActively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.\r\n\r\nSupporting Responsibilities\r\n\r\nMeet department and company performance and attendance expectations.\r\nFollow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.\r\nPerform other duties as assigned.\r\n\r\nSUCCESS PROFILE\r\nWork Experience: A minimum of 5 years of progressive experience in healthcare operations. Expertise in claims processing, clinical coding, reimbursement strategies, and/or fraud prevention required. Demonstrated success in strategic planning, vendor oversight, and cross-functional collaboration to drive operational excellence and cost containment required.\r\nEducation, Certificates, Licenses: Bachelor's degree required. Candidates with an associate's degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of Work Experience will also be considered Preferred area of focus: Healthcare Operations, Statistics, or a related field.\r\nKnowledge: Proven track record of leading operational initiatives from concept through execution, with a focus on provider reimbursement and claims payment integrity. Deep expertise in managed care claims coding, including CPT, ICD, HCPCS, Revenue Codes, and comprehensive understanding of federal and state Medicaid payment regulations. Proficient in Excel and SQL, leveraging data analysis to drive informed business decisions without reliance on technical support.\r\nCompetencies\r\nBuilding Trust\r\nBuilding a Successful Team\r\nAligning Performance for Success\r\nBuilding Partnerships\r\nCustomer Focus\r\nContinuous Improvement\r\nDecision Making\r\nFacilitating Change\r\nLeveraging Diversity\r\nDriving for Results\r\nEnvironment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.\r\nSkills\r\nAccountable leadership, Collaboration, Data-driven & Analytical, Delegation, Effective communication, Listening (active), Situational Leadership, Strategic Thinking\r\nCompensation Disclaimer\r\nThe 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.\r\nBase Range\r\n$90,052.16 - $157,591.26\r\nOur Values\r\nWe live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:\r\n\r\n\r\nWe are committed to doing the right thing.\r\n\r\n\r\nWe are one team working toward a common goal.\r\n\r\n\r\nWe are each responsible for customer service.\r\n\r\n\r\nWe practice open communication at all levels of the company to foster individual, team and company growth.\r\n\r\n\r\nWe actively participate in efforts to improve our many communities-internally and externally.\r\n\r\n\r\nWe actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.\r\n\r\n\r\nWe encourage creativity, innovation, and the pursuit of excellence.\r\n\r\n\r\nPhysical 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.\r\nDisclaimer: 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.","datePosted":"2026-04-21T04:29:55.337Z","dateModified":"2026-04-21T04:29:55.337Z","hiringOrganization":{"@type":"Organization","name":"Pacificsource","sameAs":"https://jobsearcher.com"},"jobLocation":{"@type":"Place","address":{"@type":"PostalAddress","addressLocality":"Boise","addressRegion":"ID","addressCountry":"US"}},"identifier":{"@type":"PropertyValue","name":"JobSearcher","value":"d5ce4c7c101b976d5434d06f"},"url":"https://jobsearcher.com/jobs/d5ce4c7c101b976d5434d06f"}}