Job Summary

The Director, Payment Integrity defines the payment integrity operating model. As owner, is accountable for prevention, governance, analytics, risk reduction and sustained accuracy across all prepay and post pay activity. This position is responsible for designing, leading, and continuously improving the end-to-end Payment Integrity program. This position ensures the accuracy of provider payments, minimized inappropriate spend, and strengthens preventive and detective controls across all lines of business. The Director oversees clinical editing, data mining, cost-avoidance strategies, recovery operations, coordination of benefits (COB), third-party liability (TPL), and analytical review of billing and payment patterns.

The Director sustains a Payment Integrity operating model that prevents incorrect payments before they occur, improves the reliability of claims processing through strong upstream controls, identifies systemic issues contributing...