Director, Payment Integrity – Health Plan Concierge

Role Overview

• Provides strategic leadership across the Health Plan Concierge vertical, overseeing market engagement, provider alignment, escalation management, and cross-functional coordination
• Leads teams that address provider and market needs, resolves issues effectively, and ensures market insights inform Payment Integrity priorities
• Directs forums and taskforces that translate experience signals into actionable priorities, supporting claims accuracy, reduced improper payments, and improved financial performance
• Partners with business, clinical, legal, compliance, technology, and network leaders to deliver effective provider education, strengthen governance, and drive adoption of initiatives that support sustainable medical cost savings and enterprise operational excellence
• Provides operational and strategic leadership for Payment Integrity activities within an assigned line of business, supporting market-facing efforts such as provider engagement, issue resolution, escalation management, communications and cross-functional coordination
• Executes program strategies that reduce improper payments, enhance claims accuracy, and support financial and operational objectives for the assigned business segment, ensuring alignment with broader enterprise PI goals
• Implements and maintains governance processes, controls, documentation standards, and performance measures that uphold accuracy, compliance, and operational integrity within the line of business
• Collaborates with partners across Claims, Clinical, Finance, Compliance, Provider Relations, Network, Legal, IT, and Health Plan teams to address systemic issues, resolve escalations, improve workflows, and enhance provider and member experience
• Leads insight-generation and analytics activities for the assigned line of business identifying provider pain points, operational risks, emerging trends, and opportunities to improve payment accuracy and prevent issue
• Directs provider education and communication efforts by delivering clear, consistent messaging tied to PI edits, audits, policies, and process changes and supporting successful adoption across internal and external stakeholders
• Oversees activities related to resolving complex provider issues, including coordinating supporting documentation, clarifying program requirements, and collaborating with internal partners to ensure timely and accurate case management
• Ensures compliance with CMS, Medicaid, Medicare, state regulatory requirements, coding and documentation standards, and all applicable policies, applying enterprise guidance to the unique needs of the assigned line of business
• Presents program performance, provider issue themes, savings outcomes, and risk mitigation strategies to inform prioritization, governance decisions and organizational planning
• 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 or equivalent work experience
• Master’s degree in related field preferred
• 8+ years of experience in Payment Integrity, claims operations, reimbursement methodologies, or managed care operations within a complex health plan, multi-line payer
• 3+ Experience with PI functions such as pre-pay edits, post-pay audits, analytics, or fraud/waste/abuse functions programs
• Demonstrated experience working with cross-functionally with Network, Claims, Clinical, Legal, Compliance, IT, Finance, and Health Plan leadership to resolve provider or market challenges
• Experience leading provider-facing work, including communications, education, disputes, or external stakeholder engagement
• Strong understanding of payment integrity concepts, reimbursement methodologies, provider workflows, and regulatory requirements relevant to the applicable line of business
• Demonstrated ability to use analytics and insights to identify trends, diagnose root cause, and drive operational and improvement
• Excellent communication and relationship management skills with the ability to translate complex PI programs into clear guidance for internal and external audiences
• Ability to influence across a matrixed environment and effectively communicate risk, compliance considerations, and operational impacts to expectations to leadership
• Experience with Medicaid and/or 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