Who We Are

WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready.

Culture Drives Our Success

WPS' Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an inclusive and empowering employee experience. We recognize the benefits of Diversity, Equity, and Inclusion as an investment in our workforce-both current and future-to effectively seek, leverage, and include diverse perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition

Role Snapshot

The Director of Payment Integrity will lead cross functional opportunity identification and effective delivery of WPS claim payment accuracy. This role is accountable for managing and gaining approval of WPS payment integrity expense initiatives. Initiatives will be delivered via internal operational processes as well with the use of external vendor strategies and performance management.

This leadership position is accountable for timely and clear communication of opportunities/key findings, outcomes, and improvement opportunities to all impacted business partners and cross functional teams, including clinical and medical claim coding, configuration, and financial teams at a variety of leadership levels.

In addition to this, our Director of Payment Integrity will:

• Provide leadership to ensure that the operations are managed in a manner that enhances and supports our ability to deliver meaningful cost savings through payment accuracy of claims.
• Set and manage to throughput and turnaround times, which meet and exceed customer SLAs and expectations.
• Continuously improve productivity and operational efficiency in payment accuracy delivery.
• Create and manage productivity metrics, efficiencies and claim payment accuracy.
• Establish procedures and processes to ensure service and production's smooth functioning.
• Direct operations to meet financial savings goals.
• Assist with short-term and long-range planning and budget development to support strategic business goals.
• Partner with finance to develop savings validation and measurement methodology.
• Drive savings innovation working sessions and corresponding validation efforts; coordinating proposed reimbursement policy opportunities and contract language initiatives when required.
• Design, implement and manage appropriate technological infrastructure and operational workflow processes to maximize value and ensure claims are paid correctly.
• Interfaces with and coordinates well with IT, claim processing functions, other payment integrity delivery organizations, and Finance to deliver results. This includes but is not limited to break down barriers, fund and oversee automation/new tools development and re-engineer processes.
• Lead and manage the claims cost containment area in support of all lines of business, ensuring resources are secured to effectively manage internal operations/ inventory and oversight of vendors.
• Drive and ensure alignment between claims payment processes and other enterprise processes impacted by said programs and process (e.g., claims, customer service, contracts/billing, etc.)

How do I know this opportunity is right for me? If you:

• Lead and manage the Payment Integrity organization for all lines of business, ensuring resources are secured to effectively manage internal operations/ inventory and oversight of vendors.
• Sets policies, establishes SLAs, identifies roles and responsibilities, establishes an escalation process and remediation plans, uncovers root causes, and ensure compliance of all regulatory requirement: internal, state, and federal.
• Providing oversight of vendor claim control relationships and delegation of work.
• Establish, review, implement, maintain, and monitor performance for all payment integrity operational and technology process results, including all vendor solutions, leveraging analytics, industry standard/best practices and efficient operational delivery.
• Design, implement and manage appropriate technological infrastructure and operational workflows to facilitate coordination of benefits processes that utilize a more strategic, risk-based approach to maximize value and ensure claims are paid correctly.
• Own governance and drives the partnership between internal departments ensuring end to end delivery.
• Develop strategies and implement programs to continually improve coordination of benefit processes, leveraging continuous operational improvement methodologies and/or vendor capabilities.
  • This includes network contracts, provider communications, analytical technology solutions and insuring alignment of priorities within the federated model to improve services to members and set the provider payment strategy.
• Design, collaborate, and enhance end-to-end capabilities to track and report annual claim cost containment performance to assess and achieve operational and vendor performance and goals, including the impact of claims payment processes on administrative and medical costs.
• Develop communication strategies, including dashboards of key performance indicators to ensure impacted internal and external stakeholders have the necessary awareness of results to manage change in a proactive fashion.
• Control administrative expenses and cost margins through oversight of related processes, vendors, managers, and staff activities.
• Set budget expectations and take corrective action as necessary related to budget variances for internal staff as well as vendors.
• Produce monthly, quarterly, and annual financial goals for attainment.

What will I gain from this role?

• Strong Healthcare Payment Integrity/Claim Accuracy knowledge.
• Demonstrated ability to assemble teams and develop talent.
• Demonstrated experience running production-oriented business operations.
• Demonstrated experience as an active participant in corporate decision making at a senior level.
• The ability and capacity to provide practical as well as strategic leadership and lead employee engagement.
• Experience in driving organizational development and change.
• Strong project management and process improvement skills.
• Strong analytical and problem-solving skills.
• Highly developed interpersonal skills and the ability to communicate effectively at all levels of the organization.
• Experience working in an environment that serves our nation's military, veterans, Guard and Reserves, and Medicare beneficiaries.
• Working in a continuous performance feedback environment

Minimum Qualifications

• Bachelor's degree in related field or equivalent work experience (6+ years senior level).
• At least three (3) years of direct supervisory/management experience.
• At least five (5) years of experience in the areas of medical claims payment cost containment or payment integrity.
• Knowledge of claims payment standards and regulations set forth by the National Association of Insurance Commissioners (NAIC) and state and federal regulations, including but not limited to Section 111, Medicare Payment Demand, Medicare Secondary Payer Group Health Plan Requirements, workers compensation, PIP/accident.
• Strong communication skills
• Strong experience presenting and reporting outcomes to executive leadership.
• Recent experience with IT capability development to drive and enable operational and vendor solutions.
• Demonstrated ability to develop and implement new strategies while encouraging others to do the same.
• Understanding of how to set, measure and adjustment organization metrics/key performance indicators.
• Previous experience identifying, implementing, and overseeing vendor solutions.

Preferred Qualifications

• Master of Business Administration highly preferred.
• Clinical and healthcare claims operational experience strongly preferred.
• Proven experience leading high performing teams.

Remote Work Requirements

• High speed cable or fiber internet
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net)
• Please review Remote Worker FAQs for additional information

Salary Range

$137,000 to $205,000.

The base pay offered for this position may vary based on your job-related knowledge, skills, and experience.

Work Location

We are a remote-first organization and offer remote work in the following approved states:

Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Texas, Virginia, Wisconsin

Benefits

• Remote and hybrid work options available
• Performance bonus and/or merit increase opportunities
• 401(k) with dollar-per-dollar match up to 6% of salary (100% vested immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Employee Resource Groups
• Professional and Leadership Development Programs
• Review additional benefits here

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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)