VP Cost of Care, Payment Integrity

United States

Job Description

Leader over cost of care, payment integrity, and payment policies. Establishes and manages processes around identifying and executing on cost of care initiatives. Serves as an internal consultant to Network and other departments. Leads payment policies committee. This is an individual contributor role to start but as the function matures, staff may be added to this department.

• Leads enterprise payment policy committee including cross functional interfaces 
• Supports the medical policy teams as coding expert to ensure coding is consistent and accurately represented 
• Staffs a medical code subcommittee that monitors and identifies changes to the medical code sets and ensure that all impacted stakeholders are notified. 
• Ensures coding changes are documented, implemented and audited 
• Serves as point of contact for audits of our current configuration to ensure that we do not have any gaps that might impact critical functions such as HEDIS scoring, risk adjustment etc. 
• Drives the process for annual code reviews to ensure systems are accurate 
• Conducts periodic updates of coding configurations for production systems; Participates in system design and testing. 
• Serves as expert resource on coding and provider reimbursement methodologies for other departments and subcontractors. 
• Provides regular feedback to Operations leadership on performance improvement opportunities as a result of performance gaps. 
• Identifies and interprets patterns of possible fraud or abuse and refers to Special Investigation Unit for further evaluation and corrective action. 
• Investigates, evaluates and recommends alternative solutions to meeting business needs for internal and external stakeholders. 
• Executes on identified cost of care initiatives. 

General Job Information


VP Cost of Care, Payment Integrity



Job Family

General Services Group, Operations Group


United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date


Date Requisition Created


Minimum Qualifications


Bachelors (Required), Masters

License and Certifications - Required

CCS - Certified Coding Specialist - Enterprise

License and Certifications - Preferred

Other Job Requirements


• Health insurance/managed care health plan benefits administration and/or claims configuration and implementation. 
• Participates in presentations and consultations to colleagues on coding opportunities, capabilities and performance results. 
• Documents methods, specifications and findings clearly; contributes to writing and presentation of results, findings and conclusions. 
• Reviews updates to coding standards, coding newsletters, and other professional resources to maintain up-to-date knowledge. 
• Participates in ongoing in-service programs for coding related or clinical education. 
• Coordinates and leads Coding Roundtable meetings and continuing education presentations. 
• Develops policies, procedures, and business requirements. 
• Manages personal resources efficiently to complete assigned projects accurately and on time. 
• Responsible for commitments to quality and on-time deliverables. 
• Motivated and is willing to understand and probe into technical details and data irregularities. 
• Contributes to a motivated work environment by working effectively to achieve common goals. 
BA, Health Information Management; AA, Health Information Technology.

Five years experience in Diagnosis Related Groups (DRG),

ICD-9-CM/ ICD-10-CM/PCS, CPT, and HCPCS coding and in-depth knowledge of Prospective Payment Systems;

Expertise in quality review and coding validation. 

Minimum five years Healthcare Administration and/or health insurance experience. 

Health plan business acumen required.
License/Certification: One or more of the following certifications may be required: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Associate (CCA), or Certified Professional Coder (CPC)

Experience in highly matrixed environment strongly desired. 

Masters Degree

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled