Manager Program Integrity - Prepayment Auditing , Geisinger Health Plan

Responsibilities

• Manage daily operations of the Prepayment Program Integrity function, including claim reviews and vendor edit oversight
• Develop and implement prepayment auditing strategies to support organizational compliance and payment integrity
• Oversee vendor performance, service delivery, and contractual obligations
• Manage the prepayment audit appeal process and resolve provider disputes
• Lead and develop a team of nurses, coders, auditors, and analysts
• Ensure all auditing activities comply with federal, state, and CMS regulations
• Develop executive-level reporting on audit performance, savings, and vendor effectiveness

Requirements

• High School Diploma or equivalent (Required)
• Minimum of 7 years of relevant experience
• Minimum of 2 years of managerial or supervisory experience
• Experience managing prepayment review programs and external audit vendors
• Knowledge of healthcare reimbursement methodologies and claims processing

Preferred Qualifications

• Bachelor's Degree in Nursing, Health Information Management, or Healthcare Administration
• 5+ years of experience in Payment Integrity, Claims Auditing, or Revenue Integrity
• Credentials such as RN, CPC, CCS, or CPMA
• Experience with commercial, Medicare, and Medicaid claim auditing
• Strong understanding of medical coding and clinical validation

Benefits

• Healthcare benefits including vision and dental from day one
• Benefits for domestic partners

About the Company

Geisinger is committed to making better health easier for the more than 1 million people it serves, operating nine hospital campuses, a large health plan, and a medical school.