Assistant Director of Clinical Audit, Payment Integrity
Remote option available (Except CO
Provides leadership for operational areas within Clinical Audit team. Working closely with the Director of Payment Integrity to drive strategy, process improvement and project implementation. Directs the Clinical Audit Managers, ensures delivery of pre-pay and post-pay clinical audits. Supports provider-facing functions and help ensure the execution of cost stewardship programs within the Clinical Audit team. Collaborates closely with others across Payment Integrity, Operations, Network Management, Legal and other areas of Cambia Health to align on day-to-day operations and strategy.
- Directs and organizes overall effort to create new cross-functional Payment Integrity Clinical Audit capabilities.
- Collaborates with workstreams in the development of cross-functional Payment Integrity capabilities.
- Responsible for the ongoing operation of activities falling under the Payment Integrity Clinical Audit umbrella, including post-pay and pre-pay clinical audits, coordination with Provider-facing functions, and clinical analytics.
- Ensures clear performance expectations along with appropriate skills sets. Fosters an effective work environment and ensures employees receive recognition, feedback and development. Participates in organizational talent management and succession planning.
- Partners with senior leadership in developing, implementing, and communicating short and long-range plans, goals, and objectives. Aligns team goals with the organization's vision and strategy. Identify payment integrity issues, opportunities, and effective solutions and collaborate with other departments to improve processes and deliver results.
- Handles management-level responsibilities for staff, including performance reviews, employee development, hiring, firing, coaching, counseling, and retention. Develops leaders and participates in talent management activities.
- Helps to determine appropriate staffing levels and resource needs, creates and manages department and/or project budgets, allocates resources, and approves expenditures.
- Ensures compliance with and participates in legislative initiatives and mandates including but not limited to federal, HIPAA, state mandates and URAC.
Normally to be proficient in the competencies listed above
- Knowledge of health insurance industry trends and technology including familiarity with clinical
- Audit and related functional and operational areas.
- Demonstrated ability to develop and lead high performing teams, manage managers, and direct vendors.
- Strong communication and facilitation skills with all levels of the organization, including the ability to resolve issues and build consensus among groups of diverse stakeholders.
- General business acumen including understanding of market dynamics, financial/budget management, data analysis and decision making.
- Proficiency with healthcare data, technology, and data reporting systems.
- Demonstrated ability to help create and execute operationally efficient and cost-effective programs and drive results across internal teams and/or external vendors.
- Extensive knowledge of state regulatory requirements, CMS, and demonstrated ability to manage compliant operations.
- Familiarity with clinical terminology and data.
AD, Clinical Audit would have a Bachelor's degree in healthcare, business or related field or related ten years of experience in a health care or insurance environment (to include utilization management, clinical audit, payment integrity, intake/customer service, health information management, and/or quality improvement) and five years leadership experience or equivalent combination of education and experience.
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com