Director, Payment Integrity

Job Title: Director, Payment Integrity

Reports To: Vice President, Operations

This is an exempt position reporting to the Vice President, Operations. The Director of Payment Integrity is responsible for the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams. This role functions as both the director setting strategy for these departments and the direct supervisor managing day to day operations. This position interfaces with all departments of SIHO as well as external stakeholders, vendors, and customers. The ability to interact with all levels of SIHO staff and external parties with a high level of professionalism, while adapting quickly between multiple high priority items, is essential.

Brief Description of Duties:

• Directly supervise and manage the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams, including day to day oversight, staffing, and performance management
• Read, research, and interpret federal and state regulations governing grievances and appeals, and translate regulatory requirements into practical, actionable process changes
• Continuously monitor and improve grievances and appeals processes to ensure ongoing compliance with CMS and state regulatory requirements
• Support the claims and benefit configuration quality assurance program, including developing and delivering training and education for staff
• Stay current on emerging fraud, waste, and abuse trends and lead efforts to proactively identify and investigate potential FWA
• Review results across all three departments and identify process improvement initiatives and cost savings opportunities
• Analyze department and operational data in Excel to identify trends and draw actionable insights
• Manage data transfers with vendor partners, meet with vendors regularly to ensure processes are working as intended, and escalate potential issues as they arise
• Interact directly with customers as needed
• Work with SIHO Legal and key leadership on special cases and external inquiries from CMS, the Indiana Department of Insurance, law enforcement, and others
• Develop, maintain, and report statistical measurements assessing the effectiveness of the QA, FWA, and G&A programs
• Lead or support key corporate and departmental compliance initiatives, including SOC audits, CMS Part C Reporting and ODAG, and others as assigned

Minimum Skills Requirement:

• B.S. degree or equivalent work experience in a healthcare operation
• 3-5 years experience in a managed care environment
• Strong understanding of federal and state regulations related to grievances and appeals, including CMS and state Department of Insurance requirements
• Experience across Medicare Advantage, ACA, employer group/TPA, and MEWA products preferred
• Demonstrated ability to lead and manage people and teams, while also directly supervising staff on a daily basis
• Proficient in Excel with the ability to analyze data and draw actionable insights
• Thorough understanding of medical and health plan terminology; familiarity with CPT, HCPCS, and ICD-10 coding a plus
• Excellent written and verbal communication skills, with the ability to clearly communicate with all levels of management as well as external entities, vendors, and customers
• Ability to work successfully at a self-directed pace in a changing, fast-paced, high demand environment, adapting quickly between competing high priority items
• Ability to work successfully under tight deadlines
• Experience with SIHO systems including the HSP claims system
• Proficient in Microsoft Office suite products including Word, Excel, PowerPoint, and Outlook

All positions are subject to change based on the needs of the business.

Originally posted on Himalayas