Director of Payment Integrity

Note, travel may be required for ad hoc meetings as needed in Brooklyn, OH.

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Directs a team responsible for the processing and auditing of financial disbursements for all Plan claims and provider reimbursements, while ensuring regulatory compliance. Develops and implements strategies to enhance payment accuracy and minimize financial losses. Collaborates cross-functionally and communicates with key stakeholders, including executives, providers, and government agencies.

Responsibilities

* Leads operations and staff responsible for health plan payment integrity, ensuring regulatory compliance along with payments and remittances to provider partners.

o Clinical, Coding, and High Dollar accuracy efforts

o Coordination of Benefits, Workers Compensation, and Post Pay Recovery units

o Various vendors that support operations

* Develops and leads efforts to support medical cost initiatives in partnership with stakeholders across organization. Quantifies and articulates business case to Operations and Finance.

* Brings efficiency to workflow through process improvement and transformative technologies including Robotic Process Automation (RPA), Optical Character Recognition (OCR), and Artificial Intelligence (AI). Quantifies and articulates business case to Operations and Finance.

* Collaborates with various internal departments to ensure data integrity, systems are developed/integrated and resulting financial transactions are properly recorded and processed.

* Directs the development, implementation, and maintenance of the corporate disbursements system, ensuring data integrity, reporting mechanisms and financial controls are in place to safeguard corporate assets, as well as meet legal requirements and customer needs.

* Performs other duties as assigned.

Qualifications

* Bachelor's degree in business administration, finance, or related field. In lieu of degree, may consider equivalent combination of education/training and experience. Master's Degree preferred.

* 8 years progressive experience in healthcare operations (payer or provider) or consulting, including financial information systems, and claims payment review and disbursement, 5 years of which are in a management capacity.

* Thorough knowledge of various facets of medical/claims procedures, terminology, payment analysis and claims or high-volume transaction processing systems.

* Knowledge of health plan operations and regulations.

* Proficiency with Microsoft Office and database reporting.

* Strong communication and presentation skills.

* Strong financial analysis and business acumen.

* Strong vendor relations and negotiation skills.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits and Compensation:

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance - insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year, the IRS maximum.
• Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:

Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.

At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.