Director, Payment Integrity - Hybrid

Blue Cross Blue Shield of Arizona•Phoenix, AZ

2d•Hybrid

About The Position

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. Purpose of the job The Director, Payment Integrity provides strategic leadership and oversight for all Payment Integrity functions, ensuring payment accuracy, regulatory compliance, and cost containment across medical and pharmacy claims. This role sets the vision and strategy for payment integrity programs, drives operational excellence, and partners across the enterprise to optimize reimbursement, prevent fraud/waste/abuse, and improve member affordability. The Director is accountable for developing and executing initiatives that deliver measurable savings, enhance process efficiency, and support organizational goals. This role is responsible for the performance and oversight of all Claims Payment Integrity functions and processes. These functions and processes serve to ensure appropriate payment is made for eligible members, according to contractual terms, not in error, and free of wasteful and abusive practices for all medical/pharmacy claims. This position will have accountability for leading a diverse team focused on a variety of Payment Integrity tasks including; claims payment and recovery activities, pre/post payment audit, and investigative functions. Functions of this team provide capabilities to meet regulatory, fiduciary and customer requirements and expectations to ensure over/underpayments risk are minimized and that to the extent payment issues are identified, they are remediated quickly.

Requirements

10 years of experience in Payment Integrity, Special Investigation Unit, or healthcare anti-fraud
7+ years of experience in management role
2+ years of experience in Vendor Partner Oversight; contracting and vendor management of external payment vendors and/or audit firms.
Demonstrated success in developing and executing enterprise-wide strategies.
Bachelor's Degree in business, statistics, healthcare administration or related field of study
Intermediate PC proficiency
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones.
Basic skill in word processing and presentation software
Intermediate proficiency in spreadsheet, statistical analysis, query / data mining, and business intelligence software
Advanced skill in project management
Working knowledge of classification tools (ICD, DRGs, ACGs, ETGs, etc.)
Coding Knowledge for ICD-10, CPT, or HCPCS
Risk Management Experience
Experience with Value Based Care models
Negotiation and Relationship Management
Maintain confidentiality and privacy
Communicate professionally to both internal and external customers
Analytical skills in observing and documenting processes at a detailed level
Proficiency in process improvement and business process design
Analyze and research data, propose solutions to resolve issues
Ability to use a variety of classification tools and manipulate large quantities of data
Establish, contribute and maintain a positive and productive work environment
Ability to plan, organize and manage the work of all assigned personnel
Advanced knowledge of HRIS systems, employment law, and HR regulations
Lean or Six Sigma Training
Strategic vision and enterprise leadership.
Advanced analytical, financial, and project management skills.
Expertise in coding, claims adjudication, and payment integrity technologies.
Strong negotiation, relationship management, and communication skills.
Ability to drive change, foster innovation, and build effective teams.
Ability to optimize resources to ensure a cost effective operation. Includes proactively planning to move staff from one role to another as staffing needs, business priorities or workload changes.
Ability to build effective teams
Ability to implement new processes and procedures.

Nice To Haves

15 years of experience in Payment Integrity, Special Investigation Unit, or healthcare anti-fraud
10 years of experience in management/leadership role
15+ years of experience in insurance or healthcare field
2+ years of experience in Operational Execution; scaling or improving claims review, fraud/waste/abuse programs, and overpayment recovery
Master’s Degree in business, statistics, healthcare administration or related field of study
Advanced certifications (e.g., Healthcare Fraud Studies, Lean/Six Sigma).
Experience in large-scale program management, regulatory compliance, and data analytics.
Healthcare Fraud Studies
Advanced proficiency in spreadsheet, statistical analysis, query / data mining, business intelligence software including, and data visualization tools.
Cybersecurity and Data Protection practices
Regulatory Compliance
Ability to establish and maintain professional relationships with community and professional groups which reflect favorably for the department and BCBSAZ

Responsibilities

Strategic Leadership & Program Oversight Develop and execute enterprise-wide Payment Integrity strategy aligned with organizational objectives and cost of care targets.
Lead the design, implementation, and continuous improvement of payment integrity programs, including pre- and post-payment audits, recovery, and investigative functions.
Establish and maintain governance structures, including cross-functional committees, to oversee payment integrity controls and policy development.
Representing the organization in internal and external forums, collaborating with industry peers, regulatory bodies, and vendor partners to share best practices and drive innovation.
Stay abreast of emerging trends, technologies, and regulatory shifts in the healthcare payment integrity space, proactively identifying and leveraging innovative capabilities to enhance Blue Cross Blue Shield of Arizona’s operational performance and strategic positioning.
Operational Excellence Oversee day-to-day operations, ensuring timely, accurate, and compliant claims payment and recovery activities.
Direct vendor management, including contracting, performance oversight, and strategic partnerships for payment integrity solutions.
Drive automation and technology adoption to enhance payment integrity processes and reporting capabilities.
Lead cost-benefit analyses to determine optimal resource allocation (internal vs. outsourced functions).
Financial & Data Analytics Set and monitor KPIs, SMART goals, and financial targets for payment integrity initiatives.
Oversee development of dashboards and scorecards to track program performance, savings, and operational improvements.
Partner with actuarial, finance, and analytics teams to develop business cases, forecast savings, and evaluate ROI.
Responsible for actively monitoring claims activities to ensure that identified overpayments are recouped in a timely and efficient manner.
People Leadership Build, lead, and develop a high-performing team, fostering a culture of accountability, innovation, and continuous improvement.
Provide coaching, mentorship, and professional development opportunities.
Ensure effective resource management and succession planning.
Compliance & Risk Management Ensure adherence to regulatory, fiduciary, and customer requirements.
Oversee policy and procedure development to safeguard against fraud, waste, abuse, and overpayments.
Maintain up-to-date knowledge of industry standards, compliance requirements, and emerging trends.