Manager Program Integrity – Prepayment Auditing , Get A Job.ai Health Plan

About This Opportunity

Our talent team is representing a confidential healthcare organization seeking a Manager of Program Integrity – Prepayment Auditing. This is a remote leadership role based in Pennsylvania, reporting to senior payment integrity leadership.

You will direct prepayment claims auditing programs that ensure payment accuracy and vendor compliance across professional, facility, and ancillary claims. Your team includes clinical, coding, and audit professionals who conduct fact-based reviews to reduce improper payments while maintaining strong provider relationships.

Responsibilities

• Manage daily operations of prepayment claims review and vendor edit oversight programs
• Develop and refine prepayment auditing strategies that balance payment integrity objectives with provider experience and operational efficiency
• Serve as primary business owner for prepayment audit vendors; monitor performance, accuracy, turnaround times, and contractual obligations
• Oversee prepayment claim auditing activities involving professional, facility, and ancillary claims to ensure methodologies meet industry standards and regulatory requirements
• Manage the prepayment audit appeal process; ensure timely, consistent, compliant resolution of provider disputes
• Lead and develop a team of nurses, coders, auditors, and analysts; provide coaching and performance management
• Ensure all prepayment auditing activities comply with federal and state regulations, CMS requirements, and organizational policies
• Develop executive-level reporting on audit performance, savings, provider behavior, appeal outcomes, and vendor effectiveness
• Analyze complex audit data and operational trends to support strategic decision-making and program enhancements
• Partner with clinical, legal, compliance, provider relations, and operations teams on appeals, policy improvements, and provider education

What We're Looking For

Required:

• 7+ years of relevant experience in payment integrity, claims auditing, healthcare compliance, program integrity, or revenue integrity
• 2+ years of managerial or supervisory experience
• High school diploma or equivalent (GED)

Preferred:

• Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, Business Administration, or related field
• 5+ years in payment integrity or claims auditing; 3+ years leading clinical, coding, audit, or payment integrity teams
• Experience managing prepayment review programs and external audit vendors
• Active credential: Registered Nurse (RN), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or similar
• Experience with commercial, Medicare, and Medicaid claim auditing
• Knowledge of fraud, waste, and abuse prevention programs
• Experience managing provider appeals and dispute resolution processes
• Strong understanding of medical coding, clinical validation, utilization management, and healthcare regulatory requirements

Skills: Analytical thinking, communication, critical thinking, fraud detection and prevention, leadership

Location & Schedule: Work from home (Pennsylvania); 40 hours/week; regular, exempt position

How We Work With You

Candidates apply directly through Get A Job.ai. One of our recruiters will screen your application and conduct an initial interview. If you're a strong match, we'll submit your profile to our client with your permission. Please do not contact the employer directly—all communication and interview coordination flows through our recruiting team to protect your candidacy and our client relationship.

Pay

Pay details will be discussed during the screening process and are competitive with market rates for this leadership role.

Equal Opportunity: Get A Job.ai is committed to inclusive hiring practices. All qualified applicants receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other protected category under applicable law.