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. This role functions as both the director setting strategy for these departments and the direct supervisor managing day to day operations. This position interfaces with all departments of SIHO as well as external stakeholders, vendors, and customers. 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.
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