Payment Integrity Program Manager

This role oversees inpatient Payment Integrity programs spanning audit, appeals, quality, and review operations.
You will ensure audit determinations are accurate, timely, clinically sound, and defensible.
The position combines hands-on clinical and coding expertise with program oversight and operational leadership.
You will collaborate with internal teams, offshore staff, and external vendors to maintain consistent standards.
The role also uses quality analysis, trend monitoring, and root-cause assessment to improve program performance.
As a subject matter expert, you will help resolve complex cases and support evolving audit methodologies and regulatory requirements.
This is a fully remote opportunity with broad influence across payment integrity operations and quality outcomes.

• 2–3 years of experience in healthcare auditing, Payment Integrity, coding review, clinical documentation review, or healthcare compliance.

• Strong clinical and inpatient coding expertise, with CCS, RHIA, RHIT, RN, or equivalent inpatient coding or clinical-validation experience required.

• Demonstrated expertise in inpatient DRG assignment and validation, including ICD-10-CM coding, principal and secondary diagnoses, MCC/CC identification, POA indicators, clinical documentation review, severity of illness, risk of mortality, and readmission logic.

• Experience reviewing medical records to assess audit accuracy, coding and clinical correctness, compliance, and defensibility.

• Experience working within structured audit programs, applying defined criteria, documenting rationale, and maintaining consistency across audit outcomes.

• Ability to interpret clinical and coding documentation, identify documentation gaps or discrepancies, and use evidence to support audit decisions.

• Experience collaborating across clinical, coding, audit, and operational functions within complex healthcare environments.

• Strong analytical and problem-solving skills, including the ability to identify audit trends, root causes, and documentation gaps affecting quality and performance.

• Proven experience training others on Payment Integrity auditing practices.

• Strong organizational and operational discipline, with the ability to manage multiple priorities and meet deadlines.

• Bachelor’s degree preferred.

• Strong leadership, communication, and interpersonal skills for working with internal and external stakeholders.

• Experience managing offshore vendors is preferred.

• Familiarity with AI tools, automation, or LLM-based workflows in operational environments is a plus.