Director, Payment Integrity - Coordination of Benefits and Data Mining

Job Description

Direct, manage and lead highly complex functional and/or broad foundational business areas within Payment Integrity to define and enable strategic and operational priorities. Lead and set goals for teams responsible for identifying, coordinating, and implementing initiatives/projects and activities that create efficiencies, optimize systems & processes, promote quality, and maximize medical and administrative expense savings. Teams may include Payment Integrity strategy and growth, operations, payment integrity clinical and specialty programs, and/or multiple payment integrity services either performed by vendors or internally.

Leadership Responsibilities

• People leadership
• Resource management
• Project planning and management
• Financial and data analysis

What You'll Do

• Provide leadership, vision, and direction for assigned teams. 
• Direct staff of subject matter experts and analysts to identify & execute growth business initiatives, while managing existing programs:  production problem resolution, system enhancements, and configurations. 

• Accountable to define and execute strategy to deliver year-over-year growth and achieve savings target(s) within the COB and Data Mining vertical.
• Ensure business plans and industry analysis, consider future needs and drive “best in-class" thinking.  Builds understanding of market trends and customer needs.
• Identifies new operational initiatives and modifications to current programs and processes to improve the company’s competitive position/increase medical expense savings.  
• Demonstrates understanding of the financial levers that impact business performance and deploys them to improve short- and long-term results.
• Lead and oversee management and delivery of enterprise and departmental projects including business case development, ROI analysis, planning, business analysis, and project management. 
• Lead and oversee optimization of existing systems, processes, and workflows.  
• Ensure programs and operations are performing successfully and are compliant in accordance with regulations of State, Federal, and other governing bodies; ensures corrective action plans are implemented when applicable. 
• Develop internal PI Provider Education program to enhance provider experience and focus on change in behavior.

What You'll Bring

• Bachelor’s Degree 
• 10 years of experience managing multifunctional payment integrity teams 
• In lieu of bachelor’s degree, 12 years of experience as stated above
• Must have direct health plan experience
• 7 years leadership experience 

Preferred skills

• Extensive knowledge of coordination of benefit primacy rules for commercial and Medicare lines of business, including knowledge of MSP demand process
• Basic claim coding knowledge for better understanding of data mining concepts
• Experience with project and software life cycle management
• Experience with vendor management from an operational perspective
• Experience with vendor contract negotiations
• Understanding of claims adjudication systems and pricing configuration and architecture
• Coding and billing experience

What You’ll Get:  

• The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community  

• Work-life balance, flexibility, and the autonomy to do great work   

• Medical, dental, and vision coverage along with numerous health and wellness programs   

• Parental leave and support plus adoption and surrogacy assistance