Director, Payment Integrity – Edit Programs

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Manage prepayment reviews for waste and abuse through coding, editing, and auditing programs.

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

• Supervise prepayment editing and retrospective audits to guarantee accurate and timely resolution of coding and pricing discrepancies.

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

• Design and execute continuous processes from analytic design to final reporting stages.

• Create and implement internal payment integrity editing and auditing programs, policies, and procedures.

• Stay updated on laws and regulations affecting payment integrity policies and procedures, and enforce compliant modifications.

• Suggest process enhancements that support strategic initiatives and organizational goals.

• Develop and conduct educational training sessions for providers and employees.

• Lead and mentor Prepay Compliance Managers in efforts to minimize waste, abuse, and fraud.

• Execute other duties as assigned.

• Adhere to all company policies and standards.

⛳️ Requirements

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

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

• Prior experience in claims operations is preferred.

• More than 7 years of Compliance/ERM experience is also preferred.

• Capability to comply with state and federal regulations and organizational policies.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K plan.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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

• Incentives may be included in total compensation.