Oversee prepay waste and abuse reviews through coding, editing, and audit programs
Provide guidance and set policies to ensure all programs adhere to state and federal regulations as well as company policies
Oversee prepay editing and retrospective audits to ensure accurate and timely payments of coding and pricing issues
Interpret audit results, develop action plans and present findings to senior management
Develop and implement continuous processes from analytic design to final report stage
Design, develop, and implement internal payment integrity edit and audit programs, policies, and procedures
Monitor laws and regulations that may impact payment integrity policies and procedures and implement changes while maintaining compliance with all state and federal regulations
Recommend process improvement to assist in developing and executing strategic initiatives and goals
Develop and deliver educational training programs to providers and employees to streamline operational processes and ensure accurate coding
Direct and lead Prepay Compliance Managers in their efforts to reduce waste, abuse, and fraud
Performs other duties as assigned

Bachelor’s degree in Accounting, Finance, Nursing, Operations Management, Healthcare related, or related field or equivalent experience
7+ years of finance, accounting, operations, or auditing experience
Experience in claims operations preferred
7+ years experience preferred

Director, Payment Integrity

About this role