Director, Payment Integrity Strategy & Operations

Job Summary

The Director of Payment Integrity Strategy and Operations provides strategic leadership and oversight in the design, execution, and optimization of Payment Integrity (PI) programs focused on enhancing payment accuracy and driving member affordability. This role serves as a key liaison for all reimbursement policy and PI initiatives, helping to align cost of care goals, drive ideation and prioritization, establish governance for reimbursement policies, and coordinate performance management across the program.

This leader partners closely with stakeholders in Health Care, Finance, and external payer organizations to identify, develop, and implement innovative and effective PI strategies.

JOB SPECIFICATIONS AND CORE COMPETENCIES

• Operational Oversight & Performance Management:
• Manages day-to-day PI operations, ensuring execution of process improvements and program redesigns.
• Oversees team performance, implements internal evaluations, and coordinates with vendors and solution partners.
• Guides the development of new PI models and reimbursement engagement strategies.
• Strategic Leadership & Program Development:
• Develops and drives the overall strategy for Payment Integrity (PI), aligning cost of care initiatives with enterprise goals.
• Sets SMART goals, leads ideation and vetting processes, and establishes KPIs to monitor and evaluate success.
• Parsners with actuarial and finance teams to develop business cases and monitor financial outcomes.
• Applies project management frameworks (including RACI models) to manage cross-functional initiatives.
• Drives organizational change, facilitates execution of strategic roadmaps, and aligns project milestones to overall business goals.
• Designs dashboards and reporting tools to track program performance and communicate insights to executive leadership.
• Led internal and external evaluations and aligns department metrics with corporate objectives and financial strategies.
• Reimbursement Policy & Governance:
• Leads the development and management of reimbursement policies.
• Establishes and facilitates Reimbursement Policy Governance Committees for Commercial and Medicare lines of business.
• Communicates updates, solicits feedback, and documents approvals and concerns.
• Enterprise & External Collaboration:
• Serves as a liaison and thought leader for PI across the enterprise and with external organizations and other payer organizations.
• Leads cross-functional meetings and governance committees to communicate strategy, share insights, and align on cost of care efforts.

Qualifications

• Education/Specialized Training/Licensure:
  Bachelor's degree and 10 years of experience in reimbursement policy, provider reimbursement, and/or strategic or product development required.
• Work Experience (Years and Area):
  Must have direct health plan experience required. Previous experience directly with business case development, financial and market analysis and/or process redesign Experience with Payment Integrity products and solutions required.
• Management Experience (Years and Area):
  7 years leadership experience, leading people and/or complex cross-divisional projects or programs required. History of high performance and leadership in a matrixed organization preferred.