Director, Payment Integrity

Role Overview:

• This exempt position reports to the Vice President, Operations and sets strategy for QA, Grievances & Appeals, and FWA teams.
• This role manages day-to-day operations and interacts with all SIHO departments, external stakeholders, and customers.

Key Responsibilities:

• Oversee staffing, performance management, and regulatory interpretation to maintain CMS and state compliance.
• Monitor FWA trends, manage vendor data transfers, and support claims quality assurance programs.

Qualifications:

• Requires a B.S. degree or equivalent healthcare operations experience with 3-5 years in managed care.
• Proficiency in Excel and strong understanding of Medicare Advantage, ACA, and state insurance regulations.

Compliance:

• Lead compliance initiatives including SOC audits, CMS Part C Reporting, and ODAG.
• Work with SIHO Legal and external parties including CMS and law enforcement on special cases.