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Job Details

Associate Vice President, Payment Integrity

Requisition #: 296825
Location: Johns Hopkins Health Care, Hanover, MD 21076
Category: Leadership
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: Nov. 14, 2020

Johns Hopkins HealthCare (JHHC) is the managed care and health services business of Johns Hopkins Medicine, one of the premier health delivery, academic, and research institutions in the United States. JHHC is a $2.5B business serving over 400,000 lives with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHC has become a leader in provider-sponsored health plans and is poised for future growth.

Many organizations talk about transforming the future of healthcare, Johns Hopkins HealthCare is actually doing it. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for the members and communities we serve. If you are interested in improving how healthcare is delivered, join the JHHC team.

The Associate Vice President of Payment Integrity (AVP PI) of Johns Hopkins HealthCare (JHHC) is responsible for the leadership and execution of all operational components of the Payment Integrity organization. Responsibilities include planning, directing, organizing, controlling and implementing strategic plans and initiatives that will ensure a functionally sound payment integrity structure and successful execution of all cost containment and recovery objectives. The AVP PI leads a team of 14 employees.

The Departments reporting to the AVP PI are Systems Configuration, responsible for configuring benefits, claim coding software and reimbursement schedules, Non Clinical Appeals, addressing appeals from providers related to administrative, coding and reimbursement denials, and Payment Integrity which includes pre-payment claims editing and post payment claim data mining, claim validation and recovery management, COB, Subrogation, claim coding, Fraud Waste and Abuse, Special Investigations Unit (SIU) and vendor relationship management.

Leadership Requirements

  • Building Relationships: a proven track record of building effective working relationships with direct reports and cross-functionally. Demonstrated behaviors of being open and supportive to others thoughts and feelings and an ability to gain the support and commitment of others. Demonstrated ability to inspire trust in others through consistency in words and actions.
  • Execution: Fosters team climate and business processes to deliver core operations and projects on time, within quality standards, and within budget. Relentless focus on continuous improvement of health plan operational processes and systems.
  • Vision: Establishes long-term operational strategies and near-term steps to drive change and achieve that vision.
  • Motivating & Inspiring: A demonstrated ability to keep cross-functional teams aligned and moving in the right direction.
  • Communication: Ability to communicate complex concepts to internal and external stakeholders. Communicates persuasively and articulates ideas clearly. Listens effectively and incorporates feedback into approaches, as necessary.

Principal Duties and Responsibilities

  • Provide leadership and direction for strategy and payment integrity operations to ensure strategic goals and financial objectives are met and/or exceeded
  • Developing and conducting business focused presentations across a wide variety of stake holders; Network, Clinical, Operations, Healthcare Economics, Finance and Senior Executives.
  • Driving detailed requirements for payment integrity solutions
  • Coaching and mentoring staff to build new and innovative approaches to payment integrity
  • Effectively communicating with team members, customers, partners, and management by reporting project status, and providing accurate and concise documentation
  • Communicating outcomes, data analysis, complex processes and action plans to internal and external teams
  • Staffing, employee development, and talent management
  • Recruit, select, and retain highly qualified staff; provide the leadership necessary to maintain a motivated, productive, and competent management team
  • Provide leadership and direction to build and deliver sustainable processes that ensure accuracy of claim processing and provider payments
  • Identify and drive positive collaborative relationships with key internal stakeholders

Required Skills and Experiences

  • Demonstrated success dealing with stakeholders
  • Proven transformation skills that include the ability to consistently execute at a high level,
  • Demonstrated ability to think broadly and strategically, including the ability to translate long-term goals and objectives into short-term tactical plans and operational activities.
  • Lead enterprise projects and initiatives designed to address critical business challenges and achieve organizational goals and objectives.
  • Demonstrated agility and ability to navigate complex environments.
  • Knowledge of following areas:
    • Healthcare claims life cycle
    • Claims Editing rules – Professional and Facility Rule Sets
    • Claims Cost Management – Itemized Bill Review, High Dollar Claims, 30 Day Readmissions, Predictive Analytics
    • Medical Audit and Recovery Operations – Focused Claim Review, Credit Balance, Operations Recovery, Waste and Error Post Payment Activities, Duplicate Claims Identification
    • Audit Services – DRG Coding and Compliance, Outpatient Facility, Hospital Bill Audit, Inpatient Pricing Tools
    • Investigate, review, and provide coding expertise in review of post - service, pre- payment or post payment claims, which require interpretation of state and federal mandates, billing practices / patterns, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make pay / deny or payment recommendation decisions based on findings; this could include clinical consultations
    • Healthcare Fraud and Abuse
    • Coordination of Benefits
    • Subrogation

Job Requirements:

  • Bachelor Degree in Finance, Actuarial, Accounting or other related field required.
  • Master Degree preferred.
  • Minimum of 8 years of proven, progressive experience in managing claims, Fraud Waste Abuse, Clinical Editing, Clinical coding, claims audit for Health Plans or Healthcare Services Organizations
  • Familiar with Medical Terminology.
  • Experience with Electronic Health Records (EHR).
  • Ability to manage multiple work streams, projects, tasks and goals.
  • Knowledge and experience with industry charge methodology, billing and collection regulations.
  • Comfortable working with IT and Analytic teams

Johns Hopkins Health System and its affiliates are Equal Opportunity/Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identity, sex, age, national origin, disability, protected veteran status, and or any other status protected by federal, state, or local law.

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