Senior Director, Payment Integrity – Governance

Role Overview

• Oversee a full range of waste, abuse and/or fraud investigations, audits and medical code editing scenarios
• Ensure all audits and edits adhere to federal and state Medicaid medical coding and fraud/abuse guidelines
• Oversee various functions of the Payment Integrity department for accurate and timely operational reviews and final reviews
• Interpret audit results and assist health plan executives in the development of appropriate action plans to address identified risks
• Develop and implement continuous editing and auditing processes from analytic design to final report stage
• Identify and direct the implementation of new software packages as necessary
• Ensure compliance with all state and federal regulations for waste/fraud/abuse and medical coding
• Develop corporate policies and procedures and implement corporate initiatives set upper management
• Collaborate with Providers, as needed, to train on the payment integrity rules and regulations
• Performs other duties as assigned
• Complies with all policies and standards

Requirements

• Bachelor's degree in Accounting, Criminal Justice, Finance, Medical Professional, Economics, Operations Management or related field or equivalent experience
• 10+ years of related compliance and/or special investigation experience in managed care or CMS.
• Compliance/ERM: 10+ years of experience preferred

Benefits

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• flexible approach to work