Director Payment Integrity
Core
Director overseeing Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams to ensure regulatory compliance and operational efficiency.
Role type
Director, healthcare operations compliance
Builds
compliant grievance/appeals processes, fraud detection initiatives, and operational quality programs
Domain
Healthcare / Managed Care
Required skills
regulatory compliance (CMS/state), team leadership, process improvement, data analysis (Excel), vendor management, stakeholder communication
Preferred skills
Medicare Advantage/ACA/TPA/MEWA experience, medical coding knowledge (CPT/HCPCS/ICD-10), SIHO systems familiarity
Responsibilities
Supervise QA, Grievances, and FWA teams; interpret federal/state regulations; monitor compliance processes; lead fraud investigation efforts; analyze operational data; manage vendor partnerships; report statistical measurements on program effectiveness
Seniority
Director, strategic oversight & direct management
