RAYCHEL PIENCIKOWSKI
Network Health
Little Suamico,WI
19
years of professional experience
Dynamic Payment Integrity leader with extensive experience in health plans and third-party administration, specializing in payment accuracy, audit optimization, and fraud, waste, and abuse management. Recognized for transforming ambiguity into structured accountability and aligning Payment Integrity as a vital shared service across diverse business lines. Proven track record in enhancing vendor governance, strengthening contract discipline, and delivering impactful executive reporting that drives affordability and improves medical loss ratios. Successfully navigated leadership transitions by shifting focus from compliance-based audits to value-driven initiatives prioritizing savings and operational efficiency.
Work History
Payment Integrity Manager
3 Years 7 Months- Led Payment Integrity operations and oversight for SIU/FWA coordination, payment accuracy initiatives, and vendor programs; represented the department in metrics, savings, and MLR scrutiny.
- Drove executive reporting, annual budgeting, and performance tracking to maintain visibility of PI outcomes in alignment with affordability and financial goals.
- Advanced shared-services operating model by aligning PI functions across lines of business and partnering with TPA operations to standardize approaches across varied claims systems and workflows.
- Recognized $5.6M in savings over all PI department strategies in 2025.
Payment Integrity Supervisor
5 Months- Accepted a supervisor role following unexpected leadership vacancy; stabilized the team and clarified priorities during a period of low morale and frequent leadership changes.
- Located and accounted for all PI vendor contracts for the services my team was responsible for (Itemized Bill Review, Data Mining, SNF and HHC Payment Accuracy Audits, Subrogation, Credit Balance Recovery). Created a Matrix accounting for these vendors with the contract terms to evaluate and establish a strategic plan.
- Built relationships with our contracted vendors to re-negotiate lower contingency fees and improve accuracy of invoicing and accuracy of payments to our vendors.
- Optimized audit portfolio by discontinuing low-value audits and strengthening audits with a measurable savings focus.
- Managed daily operations, ensuring compliance with healthcare regulations and organizational standards.
Senior Payment Integrity Analyst
7 Months- Joined Network Health to strengthen Payment Integrity capabilities, with early focus on audit effectiveness and SIU/FWA.
- Identified gaps in PI operating model and explored opportunities to expand value-driving functions in partnership with leadership.
Payment Policy Analyst
10 Months- Researched Medicare/Medicaid payment policy, translating regulatory updates into claims editing and reimbursement logic requirements to ensure compliance.
- Defined acceptance criteria and created test claims, validating logic in UAT to achieve compliant reimbursement outcomes.
Payment Integrity Analyst
3 Years 4 Months- Led implementation and operations of Inpatient Hospital Bill Review (IBR) program (Equian/Optum), including configuration, training, policies, vendor management, and day-to-day execution.
- Analyzed vendor-proposed pre-pay audits for payment integrity, assessing feasibility against system capabilities, reimbursement policy, and contract language; established integration procedures for audits into processing.
- Supported SIU investigations by developing fraud cases in collaboration with legal counsel, enhancing investigative outcomes.
High Dollar Claims Processor
1 Year 4 Months- Audited high-dollar claims and adjustments above established billed thresholds, validated charges, authorization, records, benefits application, and contract compliance prior to payment.
- Partnered with Medical Management and Provider Relations to resolve issues pre-payment and escalate significant payment decisions.
- Processed and adjudicated claims efficiently, ensuring compliance with insurance policies and regulations.
- Reviewed submitted documentation for accuracy, verifying completeness before processing claims.
- Coordinated with healthcare providers to resolve discrepancies and clarify claim details.
Claims Processing Specialist
1 Year 10 Months- Resolved escalated claim issues, managed inventory, processed pends and adjustments, and supported reimbursement requests for members and providers to ensure timely claims resolution.
- Processed and evaluated claims for accuracy and compliance with regulatory standards.
- Coordinated resolution of complex claim issues by collaborating with healthcare providers and clients.
- Trained new staff on claims processing procedures, enhancing team efficiency and knowledge retention.
Customer Service / Escalation Representative
6 Years 7 Months- Supported institutional provider services across multiple products; utilized COB and reimbursement methodology knowledge to effectively resolve complex provider and member issues.
- Resolved complex customer inquiries and escalations efficiently, ensuring high satisfaction levels.
Education
Associate Degree - Health Information Technology
High Honors
Skills
Payment integrity strategy
Audit portfolio optimization
Vendor management
Savings methodology governance
Root-cause analysis
Managing high performing multi-functional teams
Timeline
Payment Integrity Manager
Network Health
01.2023 - 08.2026Read More
Payment Integrity Supervisor
Network Health
08.2022 - 01.2023Read More
Senior Payment Integrity Analyst
Network Health
01.2022 - 08.2022Read More
Payment Policy Analyst
Burgess Group (HealthEdge)
03.2021 - 01.2022Read More
Payment Integrity Analyst
Wisconsin Physician Service (WPS) Health Insurance
11.2017 - 03.2021Read More
High Dollar Claims Processor
Wisconsin Physician Service (WPS) Health Insurance
07.2016 - 11.2017Read More
Claims Processing Specialist
Wisconsin Physician Service (WPS) Health Insurance
09.2014 - 07.2016Read More
Customer Service / Escalation Representative
Blue Cross and Blue Shield of New Jersey (APAC Customer Services)
10.2007 - 05.2014Read More
Northeast Wisconsin Technical College
Associate Degree from Health Information Technology
Read More