Senior Director, Payment Integrity – Audit Programs

Role Overview

• Provide strategic leadership for the Audit Programs function within Payment Integrity.
• Lead the design, execution, and continuous optimization of prepayment and post payment audit programs that improve claims accuracy, reduce improper payments, and strengthen payment controls across all applicable lines of business.
• Establish the audit program roadmap, governance, methodologies, and performance standards; oversee internal teams and external partners; and partner across the enterprise to implement solutions that deliver sustainable medical cost savings and operational excellence.
• Provide strategic leadership for enterprise payment integrity audit programs, including prepayment and post payment audits.
• Design, implement, and continuously improve audit strategies, methodologies, and governance standards.
• Oversee clinical, coding, pricing, and policy audit activities to reduce improper payments and improve claims accuracy.
• Lead the identification, prioritization, and execution of audit opportunities aligned with financial and operational goals.
• Establish performance standards, metrics, and reporting to monitor audit effectiveness, savings, and operational health.
• Leverage data and analytics to identify trends, risks, and root causes of payment errors.
• Partner with Claims, Clinical, Finance, Compliance, Legal, Provider Relations, and Technology teams to resolve issues and improve processes.
• Serve as a senior escalation point for complex audit findings, provider disputes, and operational challenges.
• Oversee external vendors supporting audit and recovery activities, ensuring quality, compliance, and performance accountability.
• Communicate audit results, risks, and recommendations clearly to senior leadership.
• Lead, develop, and mentor audit and clinical teams, fostering a culture of accountability and continuous improvement.
• Performs other duties as assigned.
• Complies with all policies and standards.

Requirements

• Bachelor’s degree in Healthcare Administration, Nursing, Finance, Accounting, Business, Operations Management, or a related field required.
• Master’s degree in Business, Healthcare Administration, Public Health, or related field preferred.
• Candidates must hold Health Information Management or coding credentials such as RHIT, RHIA, CCS, CIC, or CCDS.
• A Registered Nurse (RN) or higher qualification, in combination with a coding credential, is preferred.
• 10+ years of experience in Payment Integrity, healthcare auditing, claims operations, reimbursement methodologies, or managed care operations.
• 5+ years experience managing prepay edits, postpay audits, or fraud, waste, and abuse programs required.
• 3+ years experience in Medicaid and Medicare managed care plans strongly preferred.
• 3+ years experience implementing PI technologies (analytics, automation, vendor platforms) is a plus.
• Five (5) years of progressive managerial or supervisory experience are required.
• Candidates must demonstrate proficiency in ICD-10-CM/PCS, MS-DRG, and APR-DRG.
• Familiarity with other review types such as Readmission, APC, and EAPG is preferred.

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