Clinical Manager- Payment Integrity

Position Overview:

The Manager of Payment Integrity serves as the bridge between clinical expertise and business operations. This role evaluates payment integrity processes as it relates to carrier reimbursements, supports operational decision‑making, ensures quality and compliance, and partners with internal and external stakeholders to improve outcomes, efficiency, and experience. The Manager of Payment Integrity uses clinical knowledge, data insights, and process thinking to guide program strategy, resolve escalations, and support continuous improvement across the organization. Additionally, this role leads, manages and mentors the department’s Clinical Analysts.

Responsibilities

• Review medical records for billing accuracy and coding guidelines

• Have experience reviewing both facility and provider claims

• Understand and apply NCCI guidelines and be able to recognize common claims errors

• Review clinical documentation, guidelines, and cases to ensure accuracy, compliance, and alignment with standards

• Provide data analytics to support client and carrier requests

• Partner with internal teams to improve accuracy using data analysis and carrier feedback

• Provide clinical expertise to support operational workflows including reviewing claims data medical records

• Partner with cross‑functional teams to design and refine clinical processes that improve outcomes and efficiency

• Monitor clinical quality metrics and identify trends, gaps, and opportunities for improvement

• Prepare carrier responses on open and active referrals

• Lead carrier calls, referral calls with carrier network and clients

• Maintain accurate records of clinical policies, workflows, and quality initiatives

• Lead, manage and mentor the department’s Clinical Analyst(s)

• Collaborate with IT and serve as the liaison on business and reporting requirements for departmental IT initiatives

• Translate clinical insights into operational recommendations that improve performance, cost efficiency, and service quality

• Collaborate with Operations, Payment Integrity, and other teams to resolve escalations

• Support the development of SOPs, training materials, and process improvements

• Analyze clinical and operational data to identify patterns, risks, and opportunities

• Develop and maintain dashboards, reports, and performance summaries for leadership

• Serve as a clinical subject‑matter expert for internal teams, carriers, partners, and vendors

• Provide clear, empathetic communication to support escalations, case reviews, and program updates

• Participate in cross‑functional meetings, business reviews, and strategic planning sessions

• Develop and deliver training for internal teams on clinical guidelines, workflows, and quality expectations

• Support onboarding of new team members by providing clinical context and program knowledge

• Ensure teams understand clinical requirements that impact operations, payments, or partner experience

• Develop data visualizations with Excel or data visualization tools

Qualifications

• Active clinical license (RN, LPN/LVN or other relevant credential) preferred or inactive license with relative clinical experience or relative clinical data experience

• Bachelor’s degree in Nursing, Healthcare Administration, Business, or related field; advanced degree a plus

• At least one of the following certifications: CPC, CCS, or similar clinical/coding credential

• 5+ years in TPA/Carrier claims processing or payment integrity related areas

• 5+ years years of experience in healthcare administration, billing, claims processing, clinical auditing, payment integrity, or related areas

• Working knowledge of medical claims data, medical procedures, and healthcare workflows

• Strong attention to detail and ability to communicate clearly in writing and verbally

• Experience working with commercial health plans is a plus

• Solid analytical and critical‑thinking skills

• Preferred- experience reviewing medical records and/or claims data from a payor perspective (preferably in a medical insurance carrier setting)

• Experience working in a cross‑functional business environment strongly preferred

• Experience as a people leader/managing a team

Skills & Competencies

• Strong clinical judgment with the ability to apply guidelines and standards consistently

• Analytical mindset with experience interpreting clinical and operational data

• Excellent communication and relationship‑building skills

• Strong organizational and project‑management abilities

• Ability to navigate complex issues with professionalism, empathy, and accountability

• Proficiency with EMR systems, clinical documentation tools, or workflow platforms is a plus

Success Indicators

• High accuracy and consistency in clinical reviews and documentation

• Improved quality metrics and reduced clinical‑related escalations

• Strong cross‑functional alignment between clinical and business teams

• Clear, effective communication that supports partners and internal stakeholders

• Scalable clinical processes that support operational growth and efficiency

Who is SmartLight Analytics

SmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind, SmartLight works for self-funded employers to reduce wasteful spending in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.

Originally posted on Himalayas