• Manager of Claims Payment Integrity

    Job Locations US-RI-Smithfield
    Req No.
    Regular Full-Time
  • Overview

    This position is responsible for accurate claims adjudication and analysis for the Claims Department and its contracted vendors. Responsible for oversight of workforce management, vendor management, data analysis, internal and external policy development and management, internal training and administrative support.


    • Serves as the subject matter expert and lead on functional deliverables ensuring optimal efficiency in area of responsibility
    • Oversee department operational reporting ensuring necessary reports and dashboards are regularly and accurately produced to evaluate claims administration practices and staff performance
    • Design and implement standards and metric tools and reporting systems for staff, systems, vendors and technologies
    • Identify opportunities for improvement, through use of data, and implement changes to achieve and/or improve business results
    • Implement policy development programs for claims staff and the provider community that ensure accuracy and consistency across the organization
    • Identify, analyze, and contract with vendors to enhance opportunities for claims discounts and recoveries and other related information to ensure accurate and efficient information processing
    • Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
    • Work with the Director to develop and monitor the annual department budget
    • Monitor proposed/approved changes to state and federal law, assess the impact on claims operations and institute changes as required to remain compliant with regulations governing NHPRI and its claims processing function (e.g.: HIPAA, Prompt Claims Processing Act)
    • Other Duties as assigned
    • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.



    • Bachelor's Degree in Business Administration or related field
    • Minimum of Four (4) years in a progressively responsible leadership role(s) in health insurance or healthcare operations
    • Thorough knowledge of health insurance, including related policy provisions and exclusions, insurance laws and regulations, claims processing, medical and insurance terminology and procedure and diagnostic codes
    • Thorough knowledge of inventory management practices related to high volumes of business transactions
    • Two (2) years of leadership or supervisory experience and the ability to lead others to achieve desired results, including:
      • Ability to assess individual performance and communicate assessments effectively
      • Ability to identify and effectively and efficiently resolve employee performance problems or issues
      • Ability to establish goals and assist others to achieve goals and meet expectations
      • Ability to lead others to improve work processes.
    • Knowledgeable of provider, facility and reimbursement mechanisms
    • Analytical, problem solving, and decision-making skills, including the ability to comprehensively analyze and interpret policies, procedures and situations in a multifaceted way and possess strong problem-solving skills to develop innovative solutions to complex issues
    • Strong data analysis skills using COGNOS, Sequel, Excel
    • Proven ability to manage vendors to ensure service levels are met and performance is as contracted


    • Certified Professional Coder
    • Medicaid, Medicare and commercial experience
    • Knowledge of Quality Improvement Processes (e.g. Lean, six sigma)

    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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