Payment Integrity Program Manager

Devoted Health Services, Inc. is hiring a Payment Integrity Inpatient Program Manager to oversee inpatient Payment Integrity audit, appeals, quality, and review processes. The role performs complex audits and manages quality, timeliness, compliance, vendor performance, disputes, and program improvement across internal teams and external vendors.

Responsibilities

• 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

Preferred

• Demonstrated expertise in inpatient DRG coding and validation strongly preferred
• 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
• Inpatient DRG coding
• Bachelor’s degree
• Vendor management
• LLM-based workflows
• Operational experience
• Leadership
• Communication
• Interpersonal skills
• Prioritization
• Deadline management
• Adaptability

Benefits

• For full time employees only: employer sponsored health, dental and vision plan with low or no premium
• For full time employees only: generous paid time off
• For full time employees only: $100 monthly mobile or internet stipend
• For full time employees only: stock options for all employees
• For full time employees only: bonus eligibility for all roles excluding Director and above
• For full time employees only: commission eligibility for Sales roles
• For full time employees only: parental leave program
• For full time employees only: 401K program
• Remote USA

Company

• Medicare Advantage health insurance and clinical care for seniors
• Waltham, Massachusetts, USA
• https://devoted.com/
• Founded in 2017
• 1001-5000 employees

Qualifications

• 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 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
• Demonstrated expertise in inpatient DRG coding and validation strongly preferred
• 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

Required skills

• CCS, RHIA, RHIT, or RN Credentials, DRG Assignment and Validation, Healthcare Auditing, ICD-10-CM, Inpatient Clinical Documentation Review, Inpatient Coding and Clinical Validation, Medical Record Review, Offshore Vendor Management, Payment Integrity, Payment Integrity Audit Training, Structured Audit Programs

Preferred skills

• Bachelor's Degree, Experience managing offshore vendors

Experience

• 2-3 years