Director Payment Integrity

esident, Operations This is an exempt position reporting to the Vice President, Operations. The Director of Payment Integrity is responsible for the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams. This role functions as both the director setting strategy for these departments and the direct supervisor managing day to day operations. This position interfaces with all departments of SIHO as well as external stakeholders, vendors, and customers. The ability to interact with all levels of SIHO staff and external parties with a high level of professionalism, while adapting quickly between multiple high priority items, is essential. Brief of Duties: Directly supervise and manage the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams, including day to day oversight, staffing, and performance managementRead, research, and interpret federal and state regulations governing grievances and appeals, and translate regulatory requirements into practical, actionable process changesContinuously monitor and improve grievances and appeals processes to ensure ongoing compliance with CMS and state regulatory requirementsSupport the claims and benefit configuration quality assurance program, including developing and delivering training and education for staffStay current on emerging fraud, waste, and abuse trends and lead efforts to proactively identify and investigate potential FWAReview results across all three departments and identify process improvement initiatives and cost savings opportunitiesAnalyze department and operational data in Excel to identify trends and draw actionable insightsManage data transfers with vendor partners, meet with vendors regularly to ensure processes are working as intended, and escalate potential issues as they ariseInteract directly with customers as neededWork with SIHO Legal and key leadership on special cases and external inquiries from CMS, the Indiana Department of Insurance, law enforcement, and othersDevelop, maintain, and report statistical measurements assessing the effectiveness of the QA, FWA, and G&A programsLead or support key corporate and departmental compliance initiatives, including SOC audits, CMS Part C Reporting and ODAG, and others as assigned Minimum Skills Requirement: B.S. degree or equivalent work experience in a healthcare operation3-5 years experience in a managed care environmentStrong understanding of federal and state regulations related to grievances and appeals, including CMS and state Department of Insurance requirementsExperience across Medicare Advantage, ACA, employer group/TPA, and MEWA products preferredDemonstrated ability to lead and manage people and teams, while also directly supervising staff on a daily basisProficient in Excel with the ability to analyze data and draw actionable insightsThorough understanding of medical and health plan terminology; familiarity with CPT, HCPCS, and ICD-10 coding a plusExcellent written and verbal communication skills, with the ability to clearly communicate with all levels of management as well as external entities, vendors, and customersAbility to work successfully at a self-directed pace in a changing, fast-paced, high demand environment, adapting quickly between competing high priority itemsAbility to work successfully under tight deadlinesExperience with SIHO systems including the HSP claims systemProficient in Microsoft Office suite products including Word, Excel, PowerPoint, and Outlook All positions are subject to change based on the needs of the . \n \n Skills: exec, sys admin, education, supervisor, customer support, quality assurance, c, microsoft, ops, excel, legal, medical