Director, Payment Integrity

Role Overview

• Oversee prepay waste and abuse reviews through coding, editing, and audit programs
• Provide guidance and set policies to ensure all programs adhere to state and federal regulations as well as company policies
• Oversee prepay editing and retrospective audits to ensure accurate and timely payments of coding and pricing issues
• Interpret audit results, develop action plans and present findings to senior management
• Develop and implement continuous processes from analytic design to final report stage
• Design, develop, and implement internal payment integrity edit and audit programs, policies, and procedures
• Monitor laws and regulations that may impact payment integrity policies and procedures and implement changes while maintaining compliance with all state and federal regulations
• Recommend process improvement to assist in developing and executing strategic initiatives and goals
• Develop and deliver educational training programs to providers and employees to streamline operational processes and ensure accurate coding
• Direct and lead Prepay Compliance Managers in their efforts to reduce waste, abuse, and fraud
• Performs other duties as assigned
• Complies with all policies and standards

Requirements

• Bachelor’s degree in Accounting, Finance, Nursing, Operations Management, Healthcare related, or related field or equivalent experience
• 7+ years of finance, accounting, operations, or auditing experience
• Experience in claims operations preferred
• Compliance/ERM: 7+ years experience preferred

Benefits

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• flexible approach to work with remote, hybrid, field or office work schedules