SIHO Insurance Services
Director Payment Integrity
Salary not disclosed3–5 yearsRemote
- Operations
- Columbus
- Full time
- 1w ago
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 managing day-to-day operations and ensuring compliance with federal and state regulations. The director collaborates with internal leadership, external stakeholders, and vendors to drive process improvements and cost savings.
Responsibilities
- Supervise and manage the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams including staffing and performance management.
- Interpret federal and state regulations and translate requirements into actionable process changes.
- Monitor and improve grievance and appeals processes to ensure compliance with CMS and state requirements.
- Develop and deliver training and education for staff regarding claims and benefit configuration quality assurance.
- Identify and investigate potential fraud, waste, and abuse trends.
- Analyze operational data in Excel to identify trends and process improvement opportunities.
- Manage vendor relationships and data transfers to ensure operational effectiveness.
- Coordinate with Legal and leadership on special cases and external inquiries from regulatory bodies.
Required skills
- Managed care
- Grievances and appeals
- Quality assurance
- Fraud, waste, and abuse
- Data analysis
- Excel
- Regulatory compliance
- Medical terminology
- Microsoft Office
Nice to have
- Medicare Advantage
- ACA
- CPT coding
- HCPCS coding
- ICD-10 coding
Qualifications
- B.S. degree or equivalent work experience in a healthcare operation
About the Company
SIHO Insurance Services is a healthcare organization that manages various insurance products including Medicare Advantage, ACA, and employer group plans.