Senior Director, Payment Integrity – Audit Programs

📋 Description

• Provide strategic direction for the Audit Programs function within Payment Integrity.

• Lead the development, implementation, and ongoing enhancement of both prepayment and post-payment audit programs aimed at improving claims accuracy, minimizing improper payments, and reinforcing payment controls across all relevant business lines.

• Establish the roadmap for the audit program, along with governance, methodologies, and performance standards.

• Supervise internal teams and external partners.

• Collaborate across the organization to implement solutions that yield sustainable medical cost savings and operational excellence.

• Oversee clinical, coding, pricing, and policy audit initiatives to decrease improper payments and enhance claims accuracy.

• Drive the identification, prioritization, and execution of audit opportunities that align with financial and operational objectives.

• Set performance standards, metrics, and reporting to evaluate audit effectiveness, savings, and operational health.

• Utilize data and analytics to uncover trends, risks, and root causes of payment errors.

• Act as a senior escalation point for intricate audit findings, provider disputes, and operational issues.

• Manage external vendors engaged in audit and recovery activities, ensuring quality, compliance, and accountability for performance.

• Clearly communicate audit results, risks, and recommendations to senior leadership.

• Lead, develop, and mentor audit and clinical teams, promoting a culture of accountability and ongoing improvement.

⛳️ Requirements

• Bachelor’s degree in Healthcare Administration, Nursing, Finance, Accounting, Business, Operations Management, or a related field is required.

• A Master’s degree in Business, Healthcare Administration, Public Health, or a related area is preferred.

• Candidates must possess Health Information Management or coding credentials such as RHIT, RHIA, CCS, CIC, or CCDS.

• A Registered Nurse (RN) qualification or higher, in conjunction with a coding credential, is preferred.

• Over 10 years of experience in Payment Integrity, healthcare auditing, claims operations, reimbursement methodologies, or managed care operations.

• At least 5 years of experience managing prepay edits, postpay audits, or programs related to fraud, waste, and abuse is required.

• A minimum of 3 years of experience with Medicaid and Medicare managed care plans is strongly preferred.

• At least 3 years of experience implementing Payment Integrity technologies (analytics, automation, vendor platforms) is a plus.

• Proficiency in ICD-10-CM/PCS, MS-DRG, and APR-DRG is essential.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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