The Payment Integrity Coding Manager is responsible for developing, implementing, and continuously improving enterprise-wide payment integrity and claims programs and strategies to ensure that CareOregon’s claims editing, coding compliance, provider education, audit and recovery, and quality assurance, align with organizational goals and compliance with American Medical Association (AMA), Centers for Medicare & Medicaid Services (CMS), and state regulatory requirements.
Oversee monitoring, analysis, and reporting of claims activity (e.g., trends, outliers, high-cost claims, line-of-business segmentation).
Manage development and maintenance of tracking mechanisms, dashboards, and documentation related to audits, findings, and overpayment recoveries.
Ensure accurate invoicing and reconciliation for programs and vendors; oversee processing of recoupments and refunds.
Identify root causes of overpayments, track trends, and drive corrective actions with accountable owners.
Define and execute the enterprise payment integrity and coding audit strategy; align program goals with CareOregon’s mission, vision, values, and strategic plan.
Lead a portfolio of coding audits (prospective and retrospective), ensuring accurate capture of diagnosis and procedure codes in claims and chart review data.
Serve as subject matter expert for ICD-10-CM/PCS, CPT/HCPCS, and associated coding conventions; actively maintain and enforce AMA/CMS guidelines.

Minimum 5 years’ management experience in health plan claims operations, audit, and/or payment integrity.
Minimum 5 years’ experience as a certified coder and/or Certified Coding auditor with active certification AHIMA or AAPC (e.g., CPC, CCS, CCA, CMC or equivalent).
Preferred Experience performing statistical claims analysis in a managed care or health care setting.
Experience in and/or understanding of payment integrity programs and vendors.
Experience with SQL Server Reporting, or using business intelligence tools (e.g., Tableau) and data framework.

medical, dental, vision, life, AD&D, and disability insurance
health savings account
flexible spending account(s)
lifestyle spending account
employee assistance program
wellness program
discounts
multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)
retirement plan with employer contributions
PTO and Paid State Sick Time based on hours worked/scheduled hours

Payment Integrity Coding Manager

Key skills