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Clinical Manager – Payment Integrity
SmartLight AnalyticsManager of Payment Integrity leveraging clinical expertise to enhance payment integrity processes. Leading Clinical Analysts and collaborating with stakeholders to optimize operational outcomes and efficiencies.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical data analysis, claims processing, and operational workflows, with a strong focus on compliance and quality improvement. Proficient in leading teams and collaborating across functions to enhance clinical outcomes and efficiency.
Highest-signal resume keywords
Active Clinical LicenseCPC CertificationClaims Processing ExperienceData Analysis SkillsLeadership Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Claims DataClinical AuditingBilling AccuracyNCCI GuidelinesData VisualizationHealthcare WorkflowsClinical Documentation ReviewPerformance Metrics MonitoringSOP DevelopmentClinical Process Improvement
Soft Skills
Attention to DetailClear CommunicationEmpathyAnalytical ThinkingTeam Collaboration
Tools & Technologies
ExcelData Visualization Tools
Certifications & Qualifications
CPCCCS
Industry Keywords
Healthcare AdministrationTPAPayment IntegrityClaims ProcessingMedical Insurance Carrier
About the role
Key responsibilities & impact- 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
Requirements
What you’ll need- 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 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
Benefits
Comp & perks- Health insurance
- 401(k) matching
- Flexible work hours
- Paid time off
- Professional development opportunities