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Payment Integrity Manager
Devoted Health. Conduct prepayment and post-payment clinical reviews of inpatient admissions and related readmissions occurring within 30 days of a prior discharge .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical review processes, including prepayment and post-payment assessments of inpatient admissions and readmissions. Proficient in applying regulatory requirements and clinical criteria while maintaining accurate documentation and collaborating with internal teams.
Highest-signal resume keywords
Registered Nurse LicenseClinical Review ExperienceInpatient Readmission AssessmentElectronic Medical Records ProficiencyCritical Thinking Skills
ATS Keywords
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Hard Skills
Clinical ReviewInpatient Care KnowledgeMedical Record ReviewRegulatory Guidance ApplicationDischarge PlanningData AnalysisDocumentation PreparationQuality ReviewAudit MethodologiesProblem Solving
Soft Skills
Attention to DetailWritten CommunicationVerbal CommunicationCollaborationAnalytical Thinking
Tools & Technologies
Clinical Review SystemsAudit Workflow PlatformsElectronic Medical RecordsClaims Information Systems
Certifications & Qualifications
Registered Nurse DegreeBachelor of Science in Nursing
Industry Keywords
Payment IntegrityUtilization ManagementQuality ReviewMedicareMedicaidDRG MethodologyClinical ValidationHospital Bill Audits
About the role
Key responsibilities & impact- Conduct prepayment and post-payment clinical reviews of inpatient admissions and related readmissions occurring within 30 days of a prior discharge
- Review claims and medical records to assess clinical relationships and potential consolidation or preventability of readmissions
- Apply organizational policies, regulatory requirements, readmission criteria, and applicable exclusions
- Prepare clear, objective, timely, and defensible clinical rationales and supporting documentation
- Prepare initial findings, dispute responses, appeal letters, and review additional dispute or appeal documentation
- Collaborate with Payment Integrity, appeals, quality, utilization management, and other internal teams on complex or disputed cases
- Participate in calibration sessions, peer reviews, quality reviews, and case discussions
- Maintain accurate records in clinical review and audit systems while protecting confidential information
- Identify trends, documentation concerns, and opportunities to improve readmission review processes and outcomes
Requirements
What you’ll need- Registered Nurse degree with a current, active, and unrestricted RN license in at least one U.S. state
- Five or more years of experience in clinical nursing, hospital-based care, healthcare audit, Payment Integrity, utilization management, quality review, or a related healthcare environment
- Demonstrated experience reviewing inpatient hospital readmissions
- Strong knowledge of inpatient clinical care, disease processes, complications of care, discharge planning, and transitions of care
- Experience reviewing medical records and synthesizing clinical information from multiple sources
- Experience applying established clinical criteria, policies, regulatory guidance, and review methodologies
- Strong critical-thinking, analytical, problem-solving, and attention-to-detail skills
- Strong written and verbal communication skills
- Experience using electronic medical records, claims information, clinical review systems, or audit workflow platforms
- Bachelor of Science in Nursing or bachelor’s degree in a related healthcare field (desired)
- Experience with Medicare, Medicaid, commercial payer, QIO, State Operations Manual, or payer-specific readmission criteria (desired)
- Familiarity with inpatient coding, DRG methodology, clinical validation, or hospital bill audits (desired)
Benefits
Comp & perks- Employer sponsored health, dental and vision plan with low or no premium
- Generous paid time off
- $100 monthly mobile or internet stipend
- Stock options for all employees
- Bonus eligibility for all roles excluding Director and above
- 401K program
- Parental leave program