Job Summary
Job Summary
We are seeking a highly skilled Lead Payment Integrity Specialist to drive cost containment initiatives and ensure optimal payment accuracy across our healthcare programs. This role requires a strategic thinker with deep expertise in payment methodologies, medical spend analysis, and trend identification. The ideal candidate is passionate about uncovering opportunities for savings and implementing end-to-end Payment Integrity (PI) programs that deliver measurable results.
Essential Functions
Identify and evaluate opportunities for cost containment through detailed analysis of claims, medical spend, and utilization trends.
Design and implement comprehensive Payment Integrity programs, ensuring alignment with organizational goals and compliance standards.
Apply advanced knowledge of payment methodologies, coding practices, and reimbursement models to detect anomalies and prevent overpayments.
Lead cross-functional initiatives from concept through execution, including stakeholder engagement, operational integration, and performance monitoring.
Develop reporting and analytics to measure program impact and continuously optimize strategies.
Serves as department resource and mentor to assist in the professional development and continuing education of team. Assists in selecting, training, developing and evaluating.
Drives progress, achieving expected business outcomes, with effective: status reporting, issue escalation, risk mitigation and program decision making.
Oversees complex projects/programs with appropriate departmental and leadership relationship management, and project management. Responsible for the management of multiple projects: Develops project plans, budgets and schedules. Coordinates project work, and completes projects on time and within budget. Works with/leads the constituent Project Managers/work group leads responsible for the execution of their areas of a project to monitor cost, schedule and technical performance of component project and operation, while working to ensure the ultimate success of the program.
Organizes and works with appropriate leadership, departments and leaders to plan and schedule the coordination of people and tasks as needed to accomplish project objectives. Appropriately manages vendors from initial contracting through project completion. Serves as the leader for assignment of work activities, escalation of project related issues, service delivery, and customer satisfaction. Able to coordinate activities of numerous, diverse areas simultaneously.
Acts as project leader on the most complex special projects utilizing project management and technical computer skills to ensure all project activity is completed in an accurate timely manner including RFPs, RFIs, consolidations and conversions.
Responsible for the management of product lines which includes, but not limited to:
Analysis of product positioning and pricing in the market
Knowledge of competitor products, pricing and offerings
Development of strategies and oversight of tactics
Monitoring of business outcomes
Recommend product offerings, conducting competitive market analysis to ensure Priority Health plans are at the cutting edge
Lead cross functional teams through implementation of product design.
Qualifications
Bachelor's degree or equivalent in health care or business
7 years of relevant experience in product development lifecycle
Familiarity with state and federal regulatory and legislative processes required; must be able to read and interpret complex statutes and regulations
Ability to quickly grasp and describe health plan products and benefit designs
Extensive experience in healthcare payment integrity, claims analysis, and cost containment strategies.
Strong understanding of reimbursement methodologies (e.g., fee-for-service, DRG, capitation) and industry regulations.
Proven ability to manage complex projects and deliver results in a fast-paced environment.
Exceptional analytical, problem-solving, and communication skills.
About Corewell Health As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.
How Corewell Health cares for you
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance, pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status
Additional Details Primary Location SITE - Continuing Care - 1239 E Beltline Ave NE - Grand Rapids
Department Name Payment Integrity Planning and Implementation - PH Managed Benefits
Employment Type Full time
Shift Day (United States of America)
Weekly Scheduled Hours 40
Hours of Work 8:00 a.m. - 5:30 p.m.
Days Worked Monday - Friday
Weekend Frequency N/A
COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday account. This career site is for Non-Corewell Health team members only.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
You may request assistance in completing the application process by calling 616.486.7447.
#J-18808-Ljbffr
We are seeking a highly skilled Lead Payment Integrity Specialist to drive cost containment initiatives and ensure optimal payment accuracy across our healthcare programs. This role requires a strategic thinker with deep expertise in payment methodologies, medical spend analysis, and trend identification. The ideal candidate is passionate about uncovering opportunities for savings and implementing end-to-end Payment Integrity (PI) programs that deliver measurable results.
Essential Functions
Identify and evaluate opportunities for cost containment through detailed analysis of claims, medical spend, and utilization trends.
Design and implement comprehensive Payment Integrity programs, ensuring alignment with organizational goals and compliance standards.
Apply advanced knowledge of payment methodologies, coding practices, and reimbursement models to detect anomalies and prevent overpayments.
Lead cross-functional initiatives from concept through execution, including stakeholder engagement, operational integration, and performance monitoring.
Develop reporting and analytics to measure program impact and continuously optimize strategies.
Serves as department resource and mentor to assist in the professional development and continuing education of team. Assists in selecting, training, developing and evaluating.
Drives progress, achieving expected business outcomes, with effective: status reporting, issue escalation, risk mitigation and program decision making.
Oversees complex projects/programs with appropriate departmental and leadership relationship management, and project management. Responsible for the management of multiple projects: Develops project plans, budgets and schedules. Coordinates project work, and completes projects on time and within budget. Works with/leads the constituent Project Managers/work group leads responsible for the execution of their areas of a project to monitor cost, schedule and technical performance of component project and operation, while working to ensure the ultimate success of the program.
Organizes and works with appropriate leadership, departments and leaders to plan and schedule the coordination of people and tasks as needed to accomplish project objectives. Appropriately manages vendors from initial contracting through project completion. Serves as the leader for assignment of work activities, escalation of project related issues, service delivery, and customer satisfaction. Able to coordinate activities of numerous, diverse areas simultaneously.
Acts as project leader on the most complex special projects utilizing project management and technical computer skills to ensure all project activity is completed in an accurate timely manner including RFPs, RFIs, consolidations and conversions.
Responsible for the management of product lines which includes, but not limited to:
Analysis of product positioning and pricing in the market
Knowledge of competitor products, pricing and offerings
Development of strategies and oversight of tactics
Monitoring of business outcomes
Recommend product offerings, conducting competitive market analysis to ensure Priority Health plans are at the cutting edge
Lead cross functional teams through implementation of product design.
Qualifications
Bachelor's degree or equivalent in health care or business
7 years of relevant experience in product development lifecycle
Familiarity with state and federal regulatory and legislative processes required; must be able to read and interpret complex statutes and regulations
Ability to quickly grasp and describe health plan products and benefit designs
Extensive experience in healthcare payment integrity, claims analysis, and cost containment strategies.
Strong understanding of reimbursement methodologies (e.g., fee-for-service, DRG, capitation) and industry regulations.
Proven ability to manage complex projects and deliver results in a fast-paced environment.
Exceptional analytical, problem-solving, and communication skills.
About Corewell Health As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.
How Corewell Health cares for you
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance, pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status
Additional Details Primary Location SITE - Continuing Care - 1239 E Beltline Ave NE - Grand Rapids
Department Name Payment Integrity Planning and Implementation - PH Managed Benefits
Employment Type Full time
Shift Day (United States of America)
Weekly Scheduled Hours 40
Hours of Work 8:00 a.m. - 5:30 p.m.
Days Worked Monday - Friday
Weekend Frequency N/A
COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday account. This career site is for Non-Corewell Health team members only.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
You may request assistance in completing the application process by calling 616.486.7447.
#J-18808-Ljbffr