Director, Payment Integrity – Appeals & Disputes

This is a fully remote position, open to applicants in Illinois, +3 more states.

📋 Description

• Supervise prepay waste and abuse evaluations through coding, editing, and auditing programs.

• Offer guidance and establish policies to ensure compliance with state and federal regulations as well as company standards.

• Manage prepay editing and retrospective audits to guarantee accurate and prompt payments regarding coding and pricing discrepancies.

• Analyze audit outcomes, create action plans, and present results to senior management.

• Formulate and execute continuous processes from analytic design to the completion of reports.

• Design, create, and deploy internal payment integrity editing and auditing programs, policies, and procedures.

• Keep track of laws and regulations impacting payment integrity policies and procedures, making compliant adjustments as necessary.

• Suggest process enhancements to bolster strategic initiatives and objectives.

• Develop and provide educational training programs for providers and employees to optimize operations and ensure precise coding.

• Lead and guide Prepay Compliance Managers in efforts to mitigate waste, abuse, and fraud.

• Carry out additional duties as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Bachelor's degree in Accounting, Finance, Nursing, Operations Management, Healthcare, or a related field, or equivalent experience.

• 7+ years of experience in finance, accounting, operations, or auditing.

• Preference for candidates with experience in claims operations.

• 7+ years of experience in Compliance/ERM preferred.

• Ability to ensure compliance with state and federal regulations and company policies.

• Familiarity with coding, editing, pricing, payment integrity, and auditing programs.

• Capability to interpret audit findings and formulate action plans.

• Skill in designing and implementing analytic and reporting processes.

• Proficiency in developing and delivering educational training programs.

• Competence in leading Prepay Compliance Managers.

• Adherence to all policies and standards.

🏝️ Benefits

• Competitive compensation.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement opportunities.

• Paid time off in addition to holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.