Director - Payment Integrity Operations

Responsible for planning, organizing and leading multiple business units.  Develop the vision and strategic direction for the business units. Identify corresponding plans and priorities to achieve business unit and organizational goals. Evaluate resource availability and business unit objectives to make decisions.

• Direct the activities of assigned business units including strategic planning, problem-solving, staff development and communication.
• Develop goals and objectives for assigned business units that supports the organizations strategy, products and services.
• Collaborate across business units with key stakeholders to align business objectives.
• Oversee the development and implementation of business unit policies, systems and processes.
• Lead, direct, evaluate and develop business unit leadership and team members.
• Provide effective and efficient solutions to complex business problems.
• Prepare and present formal presentations, documents, updates, etc. to executive leadership.

"Qualifications"

• Bachelor's Degree in a related field is required. Master's Degree in a related field is preferred. 
• Five (5) years of experience in a related field is required.
• Previous experience leading a team is required.
• Ability to effectively lead, coach and develop team members.
• Ability to foster teamwork and work effectively in a cross-functional team environment.
• Advanced organizational, planning, analytical and problem-solving skills.
• Ability to solve practical problems and deal with moving variables in situations with limited standardization and alignment.
• Advanced knowledge of corporate organizational structures, including functional responsibilities.
• Advanced verbal, written communication and interpersonal skills.
• Ability to influence others to achieve business unit objectives.

Departmental Preferences:

• Experience with prepay-specific vendors and tools is preferred. 
• Prior leadership of a formal appeals or grievance team is preferred. 
• Familiarity with external audit entities (CMS RADV, OIG, state auditors) is preferred.  
• Experience with ASO client reporting and customization is preferred. 
• Strong understanding of regulatory requirements across Medicare Advantage, Medicaid, and Commercial lines of business is preferred. 
• Experience leading insourcing initiatives or transitioning vendor-based programs to internal operations is preferred. 
• Familiarity with tools such as Cotiviti, Optum CES, or other claim editing platforms is preferred.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.