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Medicaid Program Integrity Jobs in Pennsylvania (NOW HIRING)

Bcbsa

... Medicaid Services (CMS), and EGWP policies and procedures. Manage operational efficiencies ... integrity and compliance. * Relationship management skills to build and maintain a positive ...

Therakos

Government Pricing Analyst

Malvern, PA

... integrity, and timely submission of all required data. Key Responsibilities : Primary ... Medicaid Drug Rebate Program (AMP, BP, URA) * Medicare Part B (ASP) * Public Health Service / 340B ...

Mallinckrodt

Government Pricing Analyst

Malvern, PA · On-site

... integrity, and timely submission of all required data. Key Responsibilities : Primary ... Medicaid Drug Rebate Program (AMP, BP, URA) * Medicare Part B (ASP) * Public Health Service / 340B ...

Marquis Health Services

MDS Coordinator

Morrisville, PA · On-site

$36 - $60/hr

Stay current on changes to Medicare, Medicaid, and RAI/MDS regulations and guidelines. * Support ... Respect - Upholding integrity, accuracy, and confidentiality in all resident documentation and ...

Marquis Health Services

MDS Coordinator

Philadelphia, PA · On-site

$99K/yr

Stay current on changes to Medicare, Medicaid, and RAI/MDS regulations and guidelines. * Support ... Respect - Upholding integrity, accuracy, and confidentiality in all resident documentation and ...

Mazzoni Center

Controller

Philadelphia, PA · On-site

$100K - $110K/yr

... pricing programs, and Medicaid/Medicare billing. * Advanced proficiency in Microsoft Excel and ... and integrity in all aspects of work. * Participate in agency meetings, staff in-services, and ...

Merakey

Practice Manager

Lafayette Hill, PA · Remote

$26/hr

Complete Medicaid, Medicare, and other payer enrollment applications while collaborating with ... Employee discounts and savings programs on entertainment, travel, and lifestyle. * Access to Pryor ...

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All JobsMedicaid Program Integrity JobsMedicaid Program Integrity Jobs in Pennsylvania

Medicaid Program Integrity information

What is the difference between Medicaid Program Integrity vs Medicaid Claims Examiner?

AspectMedicaid Program IntegrityMedicaid Claims Examiner
Primary FocusDetecting and preventing fraud, waste, and abuse in Medicaid programsReviewing and processing Medicaid claims for accuracy and compliance
Required CredentialsTypically healthcare or compliance certifications, knowledge of Medicaid policiesHealthcare or claims processing certifications, attention to detail
Work EnvironmentRegulatory agencies, government offices, compliance departmentsInsurance companies, healthcare providers, government Medicaid offices

Medicaid Program Integrity professionals focus on safeguarding Medicaid funds by identifying fraudulent activities, while Medicaid Claims Examiners primarily verify claims for accuracy and proper coding. Both roles require healthcare knowledge and certifications but differ in their core responsibilities and work settings.

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For Medicaid Program Integrity jobs in Pennsylvania, the most frequently searched job titles are:

What job categories do people searching Medicaid Program Integrity jobs in Pennsylvania look for?

The top searched job categories for Medicaid Program Integrity jobs in Pennsylvania are:

What cities in Pennsylvania are hiring for Medicaid Program Integrity jobs?

Cities in Pennsylvania with the most Medicaid Program Integrity job openings:

Medicaid Program Integrity jobs near you

Mgr, Reimbursement & Net Rev - Finance - Full Time (Hybrid)

Guthrie

Sayre, PA • On-site

Full-time

Re-posted 2 days ago

Job description


Summary
Under the direction of the Corporate Financial Controller, the Manager of Reimbursement is responsible for the oversight, review, and integrity of the monthly Accounts Receivable (AR) valuation and net patient service revenue for all hospital entities within the integrated healthcare system. This role provides leadership and supervision to the Hospital Reimbursement Analyst and serves as a key partner to Financial Operations in analyzing and interpreting trends and variances in net patient revenue.
Responsibilities include oversight of the estimated payment process, third-party liability (TPL) reconciliations, and accounting related to Medicare and Medicaid cost report filings and settlements. The Manager also manages key third-party relationships, including reimbursement-related SaaS vendors and cost report preparation partners, ensuring service quality, data integrity, and alignment with organizational requirements. Additionally, this role evaluates and monitors third-party payer contracts to ensure accurate net revenue estimation and supports other net revenue and receivable analyses and special projects as requested.
Experience
  • Five to eight years of progressive experience in net revenue accounting, reimbursement analytics, and/or cost reporting required.
  • Demonstrated analytical and critical thinking skills with the ability to manage complex data and adapt to changing priorities.
  • Supervisory or lead experience required.
  • Familiarity with Oracle, Epic, and Kodiak RCA (formerly Crowe) strongly preferred.
  • Advanced proficiency in Excel and strong working knowledge of Word required.

Education
  • Bachelor's degree with a preferred emphasis on accounting, finance, economics, or related field of study from an accredited four-year institution. A Master's degree in Business Administration or related field and/or CPA is preferred.

Essential Functions
  • People Leadership & Oversight
    • Directly supervises the Hospital Reimbursement Analyst, providing technical guidance, performance management, and professional development.
    • Establishes priorities, ensures quality and timeliness of deliverables, and promotes consistency.
  • Net Revenue Recognition SaaS Platform Management
    • Serves as the business owner and subject matter expert for the net revenue recognition SaaS platform, overseeing monthly close activities, methodology governance, data integrity, audit support, and vendor management to ensure accurate and compliant net revenue and AR valuation reporting (see specific Key Responsibilities listed below).
  • AR Valuation & Net Revenue Analytics
    • Provide oversight and review of the monthly AR valuation and related third-party receivables and payables for hospital entities.
    • Support CFOs and Controller with analytics through analysis of trends, risks, and variances in net patient service revenue and AR reserves.
    • Analyze and project the financial impact of operational changes, payer mix shifts, and reimbursement changes to support reserve adequacy for management, audit and forecast purposes.
  • Cost Reporting & Estimated Payments
    • Manage partnership with third-party in the preparation and review of supporting schedules for all Medicare and Medicaid cost report submissions.
    • Support accounting for cost report settlements, estimated payments, and related accruals in coordination with Corporate Accounting.
    • Partner with internal and external auditors during cost report audits and desk reviews.
  • Third-Party Liability (TPL) & Contract Monitoring
    • Partner with third party professionals to research and interpret Medicare/Medicaid regulations and determine impact on entities within the Organization, become familiar with federal and state reimbursement methodologies and ensure that the Organization maintains compliance and become familiar with State and Federal reimbursement laws and regulations and third-party payor contracts and will ensure accuracy of reimbursement.
    • Partner with Revenue Cycle partners to proactively develop policies and procedures to ensure that all legitimate reimbursement is captured
    • Coordinate the preparation of Medicare/Medicaid cost reports for the System with third party professionals.
    • Oversee third-party liability reconciliations, ensuring accurate identification, valuation, and accounting of TPL payables and receivables.
    • Maintain awareness of contractual and regulatory changes affecting third-party reimbursement for acute care hospitals, freestanding ambulatory surgery centers, multi-specialty physician group practices, Home Health / Hospice services and Residency Programs.
    • Evaluate and monitor third-party payer contracts to ensure accurate net revenue estimation and consistency with system reimbursement models.
  • Cross-Functional Collaboration & Advisory
    • Partner with Financial Operations, Revenue Cycle, Accounting, and Compliance to ensure alignment of reimbursement assumptions and financial reporting.
    • Provide reimbursement expertise to leadership in support of audits, regulatory inquiries, and ad hoc financial analyses.

Other Duties
  1. Participates in committees, projects as assigned.
  2. Assists with continuing education of department and operational personnel.
  3. Performs other duties as assigned.

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About Us
Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you'll find staff members who have committed themselves to serving the community.
The Guthrie Clinic is an Equal Opportunity Employer.
The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.

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