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. 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.