Senior Director, Payment Integrity – Regulatory Oversight

Role Overview

• Provides strategic leadership for the Regulatory and Compliance Oversight function, ensuring programs remain compliant, audit‑ready, and fully traceable across all lines of business
• Leads teams responsible for regulatory interpretation, compliance readiness, audit coordination, evidence management, corrective action oversight, and regulatory intelligence
• Serves as the enterprise coordination point for regulatory inquiries and market audits, translating evolving regulations into actionable requirements and confirming alignment prior to deployment
• Partners with cross‑functional leaders to strengthen governance, maintain end‑to‑end traceability, and proactively mitigate regulatory risks through robust monitoring, clear communication, and timely issue resolution
• Provides strategic leadership for the Regulatory & Compliance Oversight vertical, ensuring PI programs are compliant, audit-ready, and fully traceable across all markets and lines of business
• Leads the development and execution of regulatory alignment strategies for PI edits, audits, recoveries, and vended solutions, ensuring accurate interpretation and consistent application of federal and state requirements
• Establishes and maintains governance frameworks, controls, documentation standards, and evidence practices that support regulatory readiness, end-to-end traceability, and sustainable compliance
• Partners with Claims, Clinical, Finance, Compliance, Provider Relations, Network, Legal, IT, and PI vertical leaders to interpret regulatory requirements, resolve compliance risks, and ensure PI program decisions reflect applicable guidelines and expectations
• Oversees regulatory intelligence and insight-generation activities, monitoring new laws, rules, sub-regulatory guidance, and GR updates
• Directs PI audit intake and response operations, including evidence collection, criteria documentation, configuration validation, sustainment tracking, and narrative preparation to support market, state, federal and vendor audits
• Provides oversight for Corrective Action Plan (CAP) management, ensuring timely closure, accurate documentation, sustainment verification, and alignment with enterprise governance processes
• Leads development and delivery of PI-specific regulatory training and knowledge-sharing, ensuring teams understand requirements, documentation expectations, regulatory impacts, and emerging compliance risks across programs, markets, and products
• Responds to PI-related regulatory inquiries, coordinate audit readiness across Medicaid, Marketplace, and Medicare/Duals hubs, communicate PI regulatory updates to internal and external stakeholders, and present regulatory risks, audit outcomes, compliance trends, and mitigation strategies to PI leadership and governance bodies
• Proactively interprets and translates regulatory updates, guidelines, and Government Relations developments into clear, actionable requirements that inform Payment Integrity programs and market operations, ensuring timely alignment and mitigation of emerging compliance risks
• Leads, develops, and mentors all levels of the team and cultivates a culture of accountability, innovation, continuous improvement, and operational rigor.

Requirements

• Bachelor’s degree in Healthcare Administration, Nursing, Finance, Accounting, Business, Operations Management, or a related field; or equivalent work experience required
• Master’s degree in related field preferred
• 10+ years of experience in Payment Integrity, regulatory compliance, audit programs, claims operations, reimbursement methodologies, or managed care operations within a complex health plan, multi-line payer required
• 4+ years of experience with PI functions such as pre-pay edits, post-pay audits, recoveries, documentation standards and PI policy development
• Proven success partnering across PI Verticals, Claims, Clinical, Legal, Compliance, Technology, Network, Finance, and Health Plan leadership to address regulatory risks and ensure program alignment to include experience developing regulatory training, evidence standards, documentation practices, and controlled communication materials for operational and technical teams
• Experience leading regulatory, audit, compliance, or oversight functions within a health plan, state Medicaid agency, CMS regulated environment, or large managed care organization
• Ability to synthesize regulatory findings, analytics, and operational insights to identify risks, root causes, and compliance improvement opportunities
• Excellent communication skills with the ability to translate complex regulatory concepts into clear guidance for internal stakeholders across diverse technical and business teams
• Demonstrated executive presence with the ability to influence across a matrixed environment and communicate risk, compliance decisions, and regulatory expectations to senior leadership
• Strong experience with Medicaid and Medicare managed care requirements and regulatory expectations, 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