Director, Payment Integrity

SIHO Insurance Services•Columbus, OH

About The Position

The Director of Payment Integrity is responsible for the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams. The role sets strategy for these departments while directly supervising staff and managing day-to-day operations. It interfaces with SIHO departments and external stakeholders, vendors, and customers, requiring professionalism and the ability to adapt quickly among high-priority matters. The position oversees regulatory compliance and process improvement for grievances and appeals; supports quality assurance for claims and benefit configuration; leads efforts to identify and investigate potential fraud, waste, and abuse; and uses departmental and operational data to identify trends, improvements, and cost-saving opportunities. The Director also manages vendor data transfers and relationships, engages with customers as needed, works with SIHO Legal and leadership on special cases and external inquiries, and develops and reports program effectiveness measures. The role leads or supports corporate and departmental compliance initiatives, including SOC audits, CMS Part C Reporting, and ODAG.

Requirements

B.S. degree or equivalent work experience in a healthcare operation.
3–5 years of 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.
Demonstrated ability to lead and manage teams while directly supervising staff on a daily basis.
Proficiency in Excel, including analyzing data and drawing actionable insights.
Thorough understanding of medical and health plan terminology.
Excellent written and verbal communication skills, including the ability to communicate clearly with all levels of management, external entities, vendors, and customers.
Ability to work successfully at a self-directed pace in a changing, fast-paced, high-demand environment and adapt quickly among competing priorities.
Ability to work successfully under tight deadlines.
Proficiency in Microsoft Office products, including Word, Excel, PowerPoint, and Outlook.

Nice To Haves

Experience across Medicare Advantage, ACA, employer group/TPA, and MEWA products.
Familiarity with CPT, HCPCS, and ICD-10 coding.
Experience with SIHO systems, including the HSP claims system.

Responsibilities

Directly supervise and manage the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams, including day-to-day oversight, staffing, and performance management.
Research and interpret federal and state regulations governing grievances and appeals, and translate requirements into practical process changes.
Monitor and improve grievances and appeals processes to maintain compliance with CMS and state regulatory requirements.
Support the claims and benefit configuration quality assurance program, including developing and delivering staff training and education.
Stay current on fraud, waste, and abuse trends and lead proactive efforts to identify and investigate potential FWA.
Review results across the three departments and identify process improvements and cost-saving opportunities.
Analyze department and operational data in Excel to identify trends and actionable insights.
Manage data transfers with vendor partners, meet with vendors regularly, and escalate issues as needed.
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 measures of the effectiveness of the QA, FWA, and G&A programs.
Lead or support corporate and departmental compliance initiatives, including SOC audits and CMS Part C Reporting and ODAG.