Director, Payment Integrity

About the role

The Director of Payment Integrity oversees the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams. This role is responsible for setting departmental strategy while managing day-to-day operations and ensuring compliance with federal and state regulations. The position involves cross-functional collaboration with internal departments, external stakeholders, and vendors to drive process improvements and cost savings.

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

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.