Sr Mgr Payment Integrity

The Senior Payment Integrity Manager -oversees and leads the two key areas: 1) Manage Curative's COB strategy, promoting accurate claim adjudication when members are covered by multiple insurance policies. This leader is responsible for identifying and verifying members' other health insurance (OHI), and applying COB rules to reduce overpayments, recover funds, and ensure compliance with federal and state regulations, including NAIC COB Model Guidelines and Medicare Secondary Payer (MSP) requirements. 2) Responsible for governing the end-to-end process of claim overpayment recovery. This role ensures accurate identification, validation, tracking, and recovery of overpaid claims across provider and pharmacy networks. The analyst will use data analysis, system tools, and internal policies to monitor
overpayment trends, support recovery initiatives, and coordinate with internal and external stakeholders.

Key Responsibilities:

COB Process Management:

• Direct daily COB operations, including subscriber record management, claim processing guidelines, investigation, and recovery activities to ensure payment accuracy,
• Manage and mentor COB analysts and claim specialists, ensuring proper training, and understanding of COB primacy rules.
• Oversee the implementation and optimization of COB processes and rules within claims systems and implementation of CAQH COB Smart.
• Optimize COB processes including analytics and automation to promote COB cost avoidance and drive year-over-year COB cost savings.
• Interpret and apply federal and state regulations related to COB, including NAIC guidelines, ERISA, MSP rules, and state-specific COB statutes.
• Collaborate with Enrollment, Provider Services, Legal, and Payment Integrity teams to resolve complex primacy disputes and COB issues.
• Monitor KPIs, recovery targets, aging reports, and audit results to drive operational improvements and meet compliance requirements.
• Ensure COB data integrity, including timely updates to member eligibility, other coverage records, and maintenance of TPL data sources (e.g., CMS COB file).
• Liaise with vendors and subcontractors performing COB functions, ensuring SLAs and quality metrics are met.
• Lead internal or external audits involving COB processing, documentation, or recoveries.

Recovery Process Management:

• Initiate and track overpayment recovery efforts including provider recoupments, offset processing, refund requests, and coordination with third-party vendors.
• Collaborate with internal audit, SIU, and legal teams to escalate suspected fraud or abuse cases

Reporting & Analysis:

• Develop dashboards and reports to track overpayment recoveries, outstanding balances, and recovery aging.
• Identify recovery trends and recommend policy or system improvements to minimize future overpayments.

Stakeholder Collaboration:

• Serve as a liaison between finance, claims operations, provider relations, and compliance teams.
• Respond to provider inquiries regarding overpayment notices and explain audit findings or recovery rationale.

Qualifications:

• Bachelor's degree in Business Administration, Health Information Management, or related field.
• 7+ years of experience in health plan claims management, with at least 3 years specializing in Coordination of Benefits.
• Strong working knowledge of COB laws and regulations (e.g., NAIC 50/50 Rule, MSP rules, ERISA coordination, commercial COB policies).
• Experience with claim adjudication systems (e.g., Facets, HealthRules Payer)
  and COB rules engines.
• Knowledge of healthcare reimbursement methodologies, provider contracts, and COB rules.
• Familiarity with COB data sources such as CMS Section 111 files, CAQH, and TPL vendors.
• Proven leadership, team management, and process improvement experience.
• Strong analytical, organizational, and conflict resolution skills.

Preferred Certifications:

• Certified Professional in Healthcare Management (CPHM)
• Certified Coordination of Benefits Specialist (if available)
• Six Sigma or Lean certification a plus

Key Competencies:

• Deep understanding of healthcare claim workflows and regulatory compliance
• Strong decision-making and problem-solving abilities
• High attention to detail with an ability to manage complex case scenarios
• Effective written and verbal communication for internal teams and external partners