Program Integrity Director Jobs in New Prague, MN

HealthPartners is hiring a Payment integrity Manager. The Payment Integrity Manager will lead the development, governance, and optimization of HealthPartners' payment and reimbursement policy framework as a core component of the Payment Integrity program.

This role is responsible for designing and maintaining clear, compliant, and operationally executable reimbursement policies that drive accurate claims adjudication, reduce provider abrasion, and ensure alignment with regulatory requirements, provider contracts, and medical policy.

The role will partner closely across Claims Operations, Provider Contracting, Medical Policy, Legal/Compliance, and Payment Integrity workstreams (pre-pay and post-pay) to translate business, clinical, and regulatory requirements into actionable policy and system logic.

This individual will initially serve as the subject matter expert and functional lead, with accountability to build and scale a high-performing payment policy function over time.

MINIMUM QUALIFICATIONS: 

• Education, Experience or Equivalent Combination:
  • Education: Bachelor's degree in Healthcare Administration, Business, Finance, or related field.
  • Experience: 6-10 years of experience in healthcare payment policy, reimbursement, claims operations, or payment integrity. 2+ years of experience leading projects, initiatives, or small teams. 
  • Equivalent Combination: An equivalent combination of education and experience may be considered in lieu of a degree.

• Knowledge, Skills, and Abilities:
  • Strong understanding of health plan operations, including claims adjudication, provider reimbursement methodologies, and benefit design.
  • Deep knowledge of reimbursement policy constructs (e.g., NCCI edits, bundling logic, payment policies, clinical editing, DRG/APC methodologies)
  • Working knowledge of Medicare, Medicaid, and Commercial reimbursement rules and regulatory requirements.
  • Experience translating policy intent into operational workflows and system configuration. (e.g., claims editing platforms such as ClaimsXten or equivalent)
  • Ability to partner cross-functionally and influence across a matrixed organization.
  • Strong analytical and problem-solving skills with ability to interpret claims data and policy impact.
  • Excellent written and verbal communication skills, particularly in policy documentation and provider-facing materials.

PREFERRED QUALIFICATIONS: 

• Education, Experience or Equivalent Combination:
  • Education: Master's degree in healthcare administration, business, public health, or related field.
  • Experience: Experience building or formalizing a payment policy governance program. Experience managing external vendors and third-party payment integrity solutions.

• Licensure/ Registration/ Certification:
  • Preferred certifications:
    • CHC (Certified in Healthcare Compliance)
    • CPC (Certified Professional Coder)
    • CCS (Certified Coding Specialist)
    • RHIA (Registered Health Information Administrator)
    • RHIT (Registered Health Information Technician)
    • Six Sigma or Lean certification for process improvement
• Knowledge, Skills, and Abilities:
  • Familiarity with CMS and state Medicaid audit protocols and compliance frameworks.
  • Advanced analytical and strategic thinking skills with the ability to translate data into actionable insights.
  • Experience with enterprise membership accounting platforms and integration with financial tools.
  • Demonstrated success in driving cost savings and operational improvements through innovation and collaboration.

ESSENTIAL DUTIES:  

1. Payment Policy Strategy & Governance (30%)

• Establish and lead the payment policy governance framework, including intake, prioritization, review, approval, and lifecycle management
• Define policy standards, templates, and decision frameworks to ensure consistency and scalability
• Partner with Payment Integrity leadership to align policy priorities with cost avoidance and savings targets
• Serve as the primary owner of reimbursement policy inventory and roadmap

2. Policy Development & Maintenance (20%)

• Develop, document, and maintain reimbursement policies across facility and professional claims
• Translate regulatory requirements, contract terms, and medical policy into clear reimbursement guidance
• Ensure policies are aligned with industry standards (e.g., NCCI, CMS guidance) and internal business objectives
• Continuously review and refine policies based on audit findings, provider feedback, and emerging trends

1. Team Leadership & Operational Oversight (20%)

• Directing medical coding review team with multi-disciplinary operational efficiency.
• Lead medical code review in conducting thorough reviews of deficiency coding and appeals.
• Coordinates timely and accurate responses to coding and appeals.
• Measures and improve efficiency and accuracy of coding and appeals.
• Promotes a culture of ethical behavior and vigilance across the organization.

3. Operationalization & System Integration (10%)

• Partner with Claims Operations and IT to translate policies into system configuration (editing logic, pricing rules, workflows)
• Ensure alignment between documented policy and system behavior to minimize discrepancies and rework
• Support testing, validation, and implementation of new or updated policies within claims platforms
• Collaborate with pre-pay and post-pay teams to ensure policies are effectively enforced

4. Cross-Functional Collaboration & Provider Impact (10%)

• Partner with Provider Contracting to align reimbursement policies with contract language and intent
• Coordinate with Legal, Compliance, and Medical Policy to ensure regulatory and clinical alignment
• Assess provider abrasion risk and support development of clear provider communication where needed
• Serve as SME for internal and external stakeholders on reimbursement policy interpretation

5. Performance Monitoring & Continuous Improvement (10%)

• Establish KPIs to measure policy effectiveness (e.g., reduction in errors, appeal rates, savings impact)
• Partner with Analytics to evaluate financial and operational impact of policies
• Identify and prioritize opportunities for new policies or enhancements based on claims trends, audits, and vendor insights
• Support audit responses and regulatory inquiries related to reimbursement practices
• Other duties as assigned

LEADERSHIP RESPONSIBILITY:

Provides leadership for the Payment / Reimbursement Policy team within HealthPartners Payment Integrity area, with oversight of the functional areas highlighted below and complete accountability for these areas from an operational excellence perspective.

Key Areas of Responsibility Include:

• Initially operates as an individual contributor / functional lead with indirect influence across multiple teams
• Expected to build and lead a small team of payment policy analysts 
• Provides direction, coaching, and oversight to ensure high-quality and consistent policy development
• Acts as a key advisor to the Director of Payment Integrity and broader leadership team

At HealthPartners we believe in the power of good - good deeds and good people working together. As part of our team, you'll find an inclusive environment that encourages new ways of thinking, celebrates differences, and recognizes hard work.

We're a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improve lives around the world.

At HealthPartners, everyone is welcome, included and valued. We're working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change.

Benefits Designed to Support Your Total Health
As a HealthPartners colleague, we're committed to nurturing your diverse talents, valuing your dedication, and supporting your work-life balance. We offer a comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities. Our goal is to help you thrive physically, mentally, emotionally, and financially, so you can continue delivering exceptional care.

Join us in our mission to improve the health and well-being of our patients, members, and communities.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identify, status as a veteran and basis of disability or any other federal, state or local protected class.