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 staff performance. The position requires frequent interaction 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.
• Interpret federal and state regulations governing grievances and appeals and translate them into actionable process changes.
• Monitor and improve 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.
• Lead efforts to proactively identify and investigate potential fraud, waste, and abuse trends.
• Analyze operational data to identify trends, process improvement initiatives, and cost savings opportunities.
• Manage data transfers with vendor partners and escalate issues as they arise.
• Collaborate with Legal and leadership on special cases and external inquiries from regulatory bodies.

Required skills

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

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.