Provider Education Program Manager - Payment Integrity

Responsibilities

• Program Development & Oversight
• Develop and maintain the health plan's provider education program for coding, documentation, and billing integrity issues, with a focus on potential upcoding and other aberrant provider billing patterns.
• Establish program workflows, referral criteria, outreach templates, monitoring schedules, escalation pathways, and reporting standards to support compliant and consistent operations.
• Create standardized processes for provider identification, educational intervention, follow-up review, and referral to SIU when concerning behavior persists.
• Data Analysis & Outlier Identification
• Analyze claims, coding, utilization, reimbursement, and provider billing data to identify outlier patterns, unusual coding distributions, trending variances, and potential upcoding concerns.
• Conduct targeted reviews using CPT, HCPCS, ICD-10, modifier usage, and documentation-related indicators to determine whether provider billing patterns warrant education or further escalation.
• Partner with payment integrity, analytics, and coding subject matter experts to validate findings, quantify impact, and prioritize outreach opportunities.
• Provider Education & Outreach
• Conduct provider outreach calls and meetings to review findings, explain coding or documentation expectations, answer questions, and reinforce compliant billing practices.
• Develop educational materials, job aids, presentations, and provider-specific feedback to support improved coding accuracy and billing compliance.
• Monitoring & Behavior Change Assessment
• Document measurable outcomes such as coding trend shifts, reduction in outlier behavior, education completion, and cases escalated for further review.
• Escalation & SIU Referral Management
• Prepare referral summaries, supporting documentation, trend analyses, and case narratives for submission to SIU, Compliance, or legal/regulatory partners as appropriate.
• What You Bring
• Bachelor's degree or advanced degree (where required)
• 8+ years of experience in related field.
• In lieu of degree, 10+ years of experience in related field.
• Bonus Points
• CPC, CCS (Required), CEMA, CPMA (Strongly Preferred), CPIP (Nice to have) or similar coding/compliance certification.
• Experience in managed care, Medicare, Medicaid, Marketplace, or commercial health plan operations.
• Experience with provider education, payment integrity vendor outputs, post-pay review, overpayment recovery, or FWA/SIU workflows.
• Advanced Excel, dashboarding, and data visualization skills. Comparable payment integrity analyst roles emphasize Excel and data analysis capability.
• Strong knowledge of CPT, HCPCS, ICD-10, modifiers, documentation standards, reimbursement methodology, CMS guidance, and payer billing requirements.
• What You'll Get
• The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community
• Work-life balance, flexibility, and the autonomy to do great work
• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match inc

Benefits

Additional Information

Job Description The Provider Education Program Manager is responsible for designing, implementing, and managing a health plan provider education program focused on identifying and addressing billing patterns indicative of potential upcoding, documentation variance, and other provider billing outliers. This role uses claims, coding, and reimbursement data to identify providers with aberrant billing patterns; develops and distributes provider education letters; conducts outreach and follow-up calls; performs quarterly and semiannual monitoring to assess behavior change; and partners with Payment Integrity, Provider Relations, Compliance, and Special Investigations Unit (SIU) teams to escalate cases when educational intervention does not result in sustained improvement.

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