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.
• Demonstrated experience with inpatient DRG assignment and validation, including ICD-10-CM coding, principal and secondary diagnosis assignment, MCC/CC identification, POA indicators, and inpatient clinical documentation review, as well as severity of illness/risk of mortality concepts and readmission logic.
• Demonstrated experience reviewing medical records to ensure audit accuracy, coding/clinical correctness, compliance, and defensibility of determinations
• Experience operating within structured audit programs, including applying defined criteria, documenting rationale, and ensuring consistency and quality of audit outcomes
• Ability to interpret clinical and/or coding documentation to support audit decisions and resolve documentation gaps or discrepancies
• Experience collaborating across clinical, coding, audit, and operational teams in a complex healthcare environment
• Strong analytical skills with the ability to assess audit trends, root causes, and documentation gaps impacting program performance and quality outcomes
• Strong operational discipline and the ability to stay organized amidst a wide variety of responsibilities
• Proven experience in training payment integrity audits

Desired skills and experience:

• Bachelor’s Degree
• Strong leadership, communication, and interpersonal skills to effectively engage internal and external stakeholders
• Experience managing offshore vendors
• Ability to handle multiple priorities and meet deadlines in a fast-paced environment
• Curiosity and hands-on experience with AI tools, automation, or LLM-based workflows in operational settings

Salary range: $73,000 - 120,000 annually

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium

• Generous paid time off

• $100 monthly mobile or internet stipend

• Stock options for all employees

• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles

• Parental leave program

• 401K program

• And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going - all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience.

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.