Director, Payment Integrity (Pre-Pay Edits) - REMOTE
About The Position
Leads and directs the team responsible for payment integrity activities, including recovery operations. The Director is responsible for team performance and quality levels, and for establishing procedures and techniques that achieve optimal operational standards and production targets. The role develops the strategic roadmap for payment integrity and oversees multiple program areas, including coordination of governance, methodology, and performance management across markets. It leads enterprise initiatives to improve financial performance, contain costs, and transform operations, while partnering with executive leadership and shared services to integrate payment integrity into corporate planning, rate setting, and compliance frameworks. The Director establishes goals, KPIs, and reporting mechanisms; provides expertise across claims processing, configuration logic, audit readiness, and vendor governance; and represents Payment Integrity in enterprise and external forums. The role also oversees vendor selection, contracting, and ROI management, advances automation and analytics, and develops leaders and succession pipelines.
Requirements
- At least 8 years of experience supporting health care operations, including 5 years of payment integrity/claims experience, or an equivalent combination of relevant education and experience.
- At least 3 years of management or leadership experience.
- Managed care payor experience; experience with Medicare/Medicaid government-sponsored programs is preferred.
- Ability to establish and maintain positive and effective work relationships with coworkers, members, providers, and customers.
- Strong organizational and time-management skills, including the ability to manage simultaneous projects and tasks to meet internal deadlines.
- Excellent verbal and written communication skills.
- Proficiency with Microsoft Office suite and applicable software programs.
Nice To Haves
- Understanding of ICD-9/10CM, MS-, AP-, and APR-DRG reimbursement.
- Electronic medical record (EMR) and medical record repository experience.
- Managed care payor experience in Medicare/Medicaid government-sponsored programs.
Responsibilities
- Develop and execute the strategic roadmap for payment integrity functions in alignment with enterprise objectives and regulatory standards.
- Oversee multiple program areas, such as COB, subrogation, data mining, pre-pay edits, and PI disputes, ensuring consistent governance, methodology, and performance management across markets.
- Lead enterprise projects and large-scale initiatives that drive financial improvement, cost containment, and operational transformation.
- Partner with executive leadership and shared services to integrate payment integrity objectives into corporate planning, rate setting, and compliance frameworks.
- Establish departmental goals, KPIs, and performance reporting mechanisms to measure and communicate enterprise payment integrity outcomes.
- Provide subject matter expertise across claims processing, configuration logic, audit readiness, and vendor governance to support accuracy and scalability.
- Represent Payment Integrity at enterprise governance meetings, shared services councils, and external regulatory discussions.
- Oversee vendor selection, contracting, and ROI management to maximize recovery efficiency and long-term value.
- Promote innovation through automation, advanced analytics, and data-driven decision-making.
- Mentor leaders and develop succession pipelines to build organizational capability and leadership readiness.
- Direct the team responsible for payment integrity activities, including recovery operations, and establish procedures and techniques to achieve operational standards and production targets.
Benefits
- Competitive benefits and compensation package.
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What This Job Offers
Job Type
Full-time
Career Level
Director
Education Level
No Education Listed
