Director, Payment Integrity

3 weeks ago

Madison, United States Wis Phys Svc Ins Corp Full time

**Who We Are**

WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready.

**Culture Drives Our Success**

WPS’ Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an inclusive and empowering employee experience. We recognize the benefits of Diversity, Equity, and Inclusion as an investment in our workforce—both current and future—to effectively seek, leverage, and include diverse perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition

**Role Snapshot**

The Director of Payment Integrity will lead cross functional opportunity identification and effective delivery of WPS claim payment accuracy. This role is accountable for managing and gaining approval of WPS payment integrity expense initiatives. Initiatives will be delivered via internal operational processes as well with the use of external vendor strategies and performance management.

This leadership position is accountable for timely and clear communication of opportunities/key findings, outcomes, and improvement opportunities to all impacted business partners and cross functional teams, including clinical and medical claim coding, configuration, and financial teams at a variety of leadership levels.

**In addition to this, our Director of Payment Integrity will**:

- Provide leadership to ensure that the operations are managed in a manner that enhances and supports our ability to deliver meaningful cost savings through payment accuracy of claims.
- Set and manage to throughput and turnaround times, which meet and exceed customer SLAs and expectations.
- Continuously improve productivity and operational efficiency in payment accuracy delivery.
- Create and manage productivity metrics, efficiencies and claim payment accuracy.
- Establish procedures and processes to ensure service and production’s smooth functioning.
- Direct operations to meet financial savings goals.
- Assist with short-term and long-range planning and budget development to support strategic business goals.
- Partner with finance to develop savings validation and measurement methodology.
- Drive savings innovation working sessions and corresponding validation efforts; coordinating proposed reimbursement policy opportunities and contract language initiatives when required.
- Design, implement and manage appropriate technological infrastructure and operational workflow processes to maximize value and ensure claims are paid correctly.
- Interfaces with and coordinates well with IT, claim processing functions, other payment integrity delivery organizations, and Finance to deliver results. This includes but is not limited to break down barriers, fund and oversee automation/new tools development and re-engineer processes.
- Lead and manage the claims cost containment area in support of all lines of business, ensuring resources are secured to effectively manage internal operations/ inventory and oversight of vendors.
- Drive and ensure alignment between claims payment processes and other enterprise processes impacted by said programs and process (e.g., claims, customer service, contracts/billing, etc.)

**How do I know this opportunity is right for me? If you**:

- Lead and manage the Payment Integrity organization for all lines of business, ensuring resources are secured to effectively manage internal operations/ inventory and oversight of vendors.
- Sets policies, establishes SLAs, identifies roles and responsibilities, establishes an escalation process and remediation plans, uncovers root causes, and ensure compliance of all regulatory requirement: internal, state, and federal.
- Providing oversight of vendor claim control relationships and delegation of work.
- Establish, review, implement, maintain, and monitor performance for all payment integrity operational and technology process results, including all vendor solutions, leveraging analytics, industry standard/best practices and efficient operational delivery.
- Design, implement and manage appropriate technological infrastructure and operational workflows to facilitate coordination of benefits process

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