Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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Director, Payment Integrity and Clinical Coding
- 💼
- EmblemHealth
- 📅
- 5 days ago Post Date
Summary of Position
Provide enterprise-wide strategic leadership for the Coding Integrity and Provider Reimbursement teams within the Payment Integrity organization. Oversee departmental operations, policies, and procedures to ensure alignment with health plan standards and compliance with federal and state regulatory requirements. Serve as the organization’s lead coding resource, advising cross-functional leaders and driving performance across internal and external programs
Principal Accountabilities
- Lead coding strategy and execution to achieve gross and incremental savings targets.
- Lead the development and enterprise-wide management of clinical coding guidelines, including the creation, maintenance, and alignment of policies with industry standards and regulatory requirements. Ensure a structured and compliant approach to coding integrity across all lines of business.
- Drive enterprise-wide operational efficiency and cost-effectiveness by leading the full lifecycle of strategic policy and coding initiatives—from development and approval through implementation and communication. Evaluate and forecast the financial impact of coding and policy changes to deliver measurable medical cost savings.
- Serve as the primary coding advisor across the enterprise, ensuring consistency and compliance.
- Lead implementation and expansion of coding-related programs, including cost-benefit analysis.
- Identify and implement improvements in systems, procedures, and workflows.
- Monitor provider abrasion and drive reductions in appeal rates and recovery adjustments.
- Deliver standardized operational processes across vendors and internal teams.
- Provide mentorship and guidance to team members, fostering a culture of collaboration, innovation, and continuous learning.
- Ideate and identify new opportunities for program growth and optimization.
- Ensure adherence to applicable federal, state, and local regulations.
- Perform other related tasks/projects as directed, requested, or required.
Qualifications
- Bachelor's Degree required
- Certified Coder (ex., CPC, CIC, CIMC)
- 10 – 12+ years of relevant, professional work experience
- 5+ years of staff/process management experience in health care or reimbursement/coding methods, preferably within a managed care environment
- 5+ years’ experience in ICD-10 & CPT-4 coding w/certification in AAPC or AHIMA for direct oversight of coding functions
- Demonstrated in-depth knowledge of state and federal regulations and CMS reimbursement methods
- Demonstrated experience in the development and delivery of employee training/development
- Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.)
- Outstanding attention to detail and organizational, quantitative, and analytical abilities
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.