MCO Director Payment Integrity

Amerihealth Caritas Health Plan•Newtown Square, PA

41d•Remote

About The Position

The Director of Payment Integrity Solutions is responsible for overseeing Payment Integrity edit and program strategy and performance across all ACFC lines of business and products (Medicaid, Medicare, Exchange, PBM, BH). This role ensures that implemented solutions deliver measurable value through rigorous analytics, including the use of artificial intelligence (AI), machine learning (ML), and NLP-based automation, coupled with continuous policy refinement, and strong Plan and provider stakeholder engagement. The Director leads efforts to monitor effectiveness, address operational gaps, support provider escalations, and guide ongoing improvements in payment integrity strategies and support systems. Key to the role is shifting post-payment projects, where possible, left for prospective adjudication. A key accountability includes managing the Payment Integrity Support Desk to ensure timely and high-quality issue resolution and feedback integration. This role is critical to sustaining and optimizing enterprise-wide payment accuracy and Fraud Waste and Abuse (FWA) program compliance.

Requirements

At least five to ten (5 -10) experience in strategic leadership, policy development, provider relations and stakeholder engagement, and reporting and insights
At least ten (10) or more years of experience in managed care operations/administration
Working knowledge of CMS guidance and experience with Medicaid
Working knowledge of payment integrity regulations and requirements
Experience with claims adjudication platforms (Facets, QNXT, HealthRules, Peradigm/Diamond, etc.)
Bachelor's Degree
Ability to design and lead complex policy and product strategies that align with regulatory, operational, and financial objectives
Demonstrated history of success in triaging, resolving, and optimizing cross-functional processes within managed care organizations
Ability to work collaboratively with internal associates and external stakeholders and drive to expedited resolution
Experience with vendor oversight
Strong track record in using data analytics, reporting tools, and KPIs to drive business decisions, monitor outcomes, and support audit readiness
Exceptional written and verbal communication skills with the ability to translate complex regulatory and technical content into user-friendly formats for providers and internal teams
Demonstrated ability to think with the enterprise in mind
Experience with vendor oversight and negotiating contracts

Responsibilities

Develop and manage enterprise-wide payment integrity policies and strategy across all products
Lead cross-functional governance activities to refine and evolve payment integrity programs based on performance outcomes and regulatory changes
Collaborate with legal, compliance, analytics, clinical policy, provider network, PI vendors, and other internal/external key stakeholders to ensure regulatory alignment and mitigate audit risk
Lead the development of provider engagement strategies that promote transparency and trust throughout the claims auditing process
Act as a liaison between payment integrity operations and provider network management to address escalations and improve end-user experiences; also, represent payment integrity in escalated provider meetings
Design and deliver training, education campaigns, and supporting materials tailored to provider audiences to clarify processes, reduce disputes, and improve outcomes
Direct development of performance dashboards, predictive analytics, and root-cause analysis to assess impact and identify areas for improvement
Translate data findings into actionable business insights to inform strategy, training content, and policy revisions
Use analytics to proactively identify emerging issues, support audit readiness, and drive continuous optimization
Evaluate and implement AI-driven solutions, including machine learning, natural language processing (NLP), and predictive models to identify improper payments and reduce manual effort
Help drive automation-first thinking across prepay and post-pay processes to reduce turnaround times and improve accuracy
Help develop governance structure to evaluate AI vendor deliverables, ROI, and ongoing performance monitoring
Lead and manage the Payment Integrity Support Desk function to ensure prompt triage and resolution of provider and internal inquiries
Monitor service levels, identify trends in support requests, and escalate systemic issues for operational correction
Utilize insights from support interactions to inform broader strategies, training needs, and process enhancements