Payment Integrity Program Manager

Job Description

A bit about this role:

The Payment Integrity Inpatient Program Manager is responsible for overseeing assigned inpatient Payment Integrity programs, including audit, appeals, quality, and review processes across internal teams, offshore staff augmentation, and external vendors. This role is heavily focused on ensuring audit accuracy, timeliness, coding and clinical quality, regulatory compliance, consistency, and defensibility across all assigned program areas.

The Program Manager is accountable not only for the quality of audit determinations but also for ensuring audits are reviewed within SLA and that inventory is actively managed to prevent backlogs.

The Program Manager partners closely with leadership and operational support teams to ensure audit workflows are executed effectively and on time while maintaining strong oversight of audit quality, turnaround performance, dispute outcomes, vendor performance, and adherence to organizational and regulatory standards.

Your Responsibilities and Impact will include:

• Perform complex and escalated inpatient Payment Integrity audits, including clinical validation, DRG coding validation, readmission, and hospital bill audit reviews, and provide clear, defensible audit rationale and determinations.
• Provide guidance and oversight to internal staff (offshore and stateside)) and external vendors, managing calibration sessions, feedback loops, education, and ongoing quality monitoring to ensure compliance and adherence to program expectations
• Develop and maintain program-specific training materials, audit guidance, review standards, and supporting documentation
• Perform quality reviews and trend analysis to ensure coding, clinical, and audit findings are accurate, defensible, and aligned with regulatory, contractual, and organizational requirements
• Monitor program metrics, dispute trends, and vendor results, partnering with leadership to identify root causes, address quality concerns, and drive continuous improvement efforts
• Collaborate with internal and external stakeholders to resolve complex audit, coding, clinical, and escalation-related issues, serving as the primary subject matter expert for assigned program areas
• Support dispute and appeals management activities, including escalation review, audit rationale review, and corrective action planning
• Support the implementation of new audit concepts, review methodologies, and program enhancements to align with evolving business and regulatory needs
• Required skills and experience: 2-3 years of experience in healthcare audit, Payment Integrity, coding review, clinical documentation review, or compliance

Strong clinical and inpatient coding knowledge required; CCS, RHIA, RHIT, RN, or equivalent inpatient coding/clinical validation experience required. Demonstrated expertise in inpatient DRG coding and validation strongly preferred.