Associate Director - Payment Integrity

We are seeking an experienced Associate Director – Payment Integrity to lead fraud, waste, and abuse (FWA) prevention, claims auditing, and cost-containment strategies in healthcare payer operations. This role will drive payment integrity initiatives, ensuring accurate claim payments, regulatory compliance, and financial recovery optimization. The ideal candidate will have strong expertise in healthcare claims processing, provider billing practices, medical policy, and data analytics to enhance payment accuracy and reduce improper payments. 

Key Responsibilities 

Payment Integrity Strategy & Execution: 

• Develop and implement payment integrity programs to identify and prevent fraud, waste, abuse, and billing errors in claims processing. 

• Oversee pre-payment and post-payment audits, medical necessity reviews, and provider billing investigations. 

• Collaborate with SIU (Special Investigations Unit) and compliance teams to address fraudulent claims. 

• Optimize overpayment identification, recovery processes, and provider education initiatives. 

Claims Review & Compliance: 

• Ensure compliance with CMS, Medicaid, Medicare Advantage, ACA, and commercial payer regulations. 

• Oversee claims adjudication accuracy, DRG validation, coding audits (ICD-10, CPT, HCPCS), and reimbursement validation. 

• Partner with legal and regulatory teams to interpret evolving healthcare payment policies and ensure adherence. 

Data Analytics & Technology Integration: 

• Leverage AI, machine learning, and predictive analytics to detect patterns of improper payments and high-risk claims. 

• Work with IT and data science teams to enhance payment integrity tools, dashboards, and reporting capabilities. 

• Utilize data-driven insights to recommend policy updates and process improvements. 

Cross-Functional Collaboration & Stakeholder Management: 

• Work closely with finance, claims, provider relations, medical management, and actuarial teams to drive payment accuracy. 

• Engage with third-party vendors, auditors, and external consultants for payment integrity solutions. 

• Develop and present executive-level reports on financial recoveries, savings, and operational efficiencies. 

Operational Leadership & Continuous Improvement: 

• Lead and mentor a team of payment integrity analysts and audit specialists. 

• Establish KPIs, SLAs, and performance metrics to monitor the effectiveness of payment integrity programs. 

• Identify opportunities to enhance operational workflows, automation, and process efficiencies. 

Qualifications & Requirements 

Education & Experience: 

• Bachelor’s degree in healthcare administration, Business, Finance, or a related field (Master’s preferred). 

• 8+ years of experience in healthcare payment integrity, claims auditing, or fraud detection. 

• 3+ years in a leadership role overseeing payment integrity programs or healthcare cost-containment strategies. 

Skills & Competencies: 

• Strong knowledge of healthcare claims processing, provider reimbursement models, and payment methodologies (fee-for-service, capitation, value-based payments, etc.). 

• Experience with CMS regulations, state Medicaid rules, and commercial payer compliance. 

• Proficiency in healthcare fraud analytics, data mining, and predictive modeling. 

• Knowledge of coding audits (ICD-10, CPT, DRG, HCPCS), medical policies, and utilization management. 

• Strong stakeholder management, problem-solving, and communication skills. 

Preferred Qualifications: 

• Certifications such as Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), or AAPC/AHIMA credentials. 

• Experience with payment integrity platforms, claims analytics tools (e.g., Cotiviti, Optum, Change Healthcare, etc.), and AI-driven fraud detection. 

• PMP, Six Sigma, or Agile certification.