Product Specialist Lead

We are seeking a highly skilled Lead Payment Integrity Specialist to drive cost containment initiatives and ensure optimal payment accuracy across our healthcare programs. This role requires a strategic thinker with deep expertise in payment methodologies, medical spend analysis, and trend identification. The ideal candidate is passionate about uncovering opportunities for savings and implementing end-to-end Payment Integrity (PI) programs that deliver measurable results.

• Identify and evaluate opportunities for cost containment through detailed analysis of claims, medical spend, and utilization trends.
• Design and implement comprehensive Payment Integrity programs, ensuring alignment with organizational goals and compliance standards.
• Apply advanced knowledge of payment methodologies, coding practices, and reimbursement models to detect anomalies and prevent overpayments.
• Lead cross-functional initiatives from concept through execution, including stakeholder engagement, operational integration, and performance monitoring.
• Develop reporting and analytics to measure program impact and continuously optimize strategies.
• Serves as department resource and mentor to assist in the professional development and continuing education of team. Assists in selecting, training, developing and evaluating.
• Drives progress, achieving expected business outcomes, with effective: status reporting, issue escalation, risk mitigation and program decision making.
• Oversees complex projects/programs with appropriate departmental and leadership relationship management, and project management. Responsible for the management of multiple projects: Develops project plans, budgets and schedules. Coordinates project work, and completes projects on time and within budget. Works with/leads the constituent Project Managers/work group leads responsible for the execution of their areas of a project to monitor cost, schedule and technical performance of component project and operation, while working to ensure the ultimate success of the program.
• Organizes and works with appropriate leadership, departments and leaders to plan and schedule the coordination of people and tasks as needed to accomplish project objectives. Appropriately manages vendors from initial contracting through project completion. Serves as the leader for assignment of work activities, escalation of project related issues, service delivery, and customer satisfaction. Able to coordinate activities of numerous, diverse areas simultaneously.
• Acts as project leader on the most complex special projects utilizing project management and technical computer skills to ensure all project activity is completed in an accurate timely manner including RFP's, RFI's, consolidations and conversions.
• Responsible for the management of product lines which includes, but not limited to:
  - Analysis of product positioning and pricing in the market
  - Knowledge of competitor products, pricing and offerings
  - Development of strategies and oversight of tactics
  - Monitoring of business outcomes
• Recommend product offerings, conducting competitive market analysis to ensure Priority Health plans are at the cutting edge
• Lead cross functional teams through implementation of product design.

Required

• Bachelor's degree or equivalent in health care or business

• 7 years of relevant experience in product development lifecycle
• Familiarity with state and federal regulatory and legislative processes required; must be able to read and interpret complex statutes and regulations
• Ability to quickly grasp and describe health plan products and benefit designs

• Extensive experience in healthcare payment integrity, claims analysis, and cost containment strategies.
• Strong understanding of reimbursement methodologies (e.g., fee-for-service, DRG, capitation) and industry regulations.
• Proven ability to manage complex projects and deliver results in a fast-paced environment.
• Exceptional analytical, problem-solving, and communication skills.

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.

• On-demand pay program powered by Payactiv

• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!

• Optional identity theft protection, home and auto insurance, pet insurance

• Traditional and Roth retirement options with service contribution and match savings

• Eligibility for benefits is determined by employment type and status

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Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.