Director, Payment Integrity - Appeals & Disputes

About the role

Oversee prepay waste and abuse reviews through coding, editing, and audit programs. Provide guidance and set policies to ensure all programs adhere to state and federal regulations as well as company policies.

Responsibilities

• Oversee prepay editing and retrospective audits to ensure accurate and timely payments of coding and pricing issues.
• Interpret audit results, develop action plans, and present findings to senior management.
• Design, develop, and implement continuous processes from analytic design to final report stage.
• Design, develop, and implement internal payment integrity edit and audit programs, policies, and procedures.
• Monitor laws and regulations that may impact payment integrity policies and procedures and implement changes while maintaining compliance with all state and federal regulations.
• Recommend process improvement to assist in developing and executing strategic initiatives and goals.
• Develop and deliver educational training programs to providers and employees to streamline operational processes and ensure accurate coding.
• Direct and lead Prepay Compliance Managers in their efforts to reduce waste, abuse, and fraud.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements

• Bachelor’s degree in Accounting, Finance, Nursing, Operations Management, Healthcare related, or related field or equivalent experience.
• 7+ years of finance, accounting, operations, or auditing experience.
• Experience in claims operations preferred.
• 7+ years of compliance/ERM experience preferred.

Pay

Pay Range: $118,400.00 - $219,000.00 per year. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible approach to work with remote, hybrid, field, or office work schedules

Benefits may be subject to program eligibility.