Director Payment Integrity

About the role

The Director of Payment Integrity oversees the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams. This role involves setting departmental strategy while providing direct supervision for daily operations. The position requires collaboration with internal departments, external stakeholders, and vendors to ensure regulatory compliance and operational efficiency.

Responsibilities

• 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

Required skills

• Managed care
• Regulatory compliance
• Grievances and appeals
• Data analysis
• Excel
• Microsoft Office
• Team leadership
• Medical terminology

Nice to have

• Medicare Advantage
• ACA
• CPT coding
• HCPCS coding
• ICD-10 coding

Qualifications

• Bachelor's degree in a healthcare operation or equivalent work experience

About the Company

SIHO Insurance Services is a healthcare organization that manages various insurance products including Medicare Advantage, ACA, and employer group plans.