Director of Payment Integrity & Regulatory Compliance

Siho Insurance Group; Columbus (IN); Hybrid; USD 120,000 - 180,000; Full time

Job summary

Siho Insurance Group is seeking a Director, Payment Integrity to lead the QA, Grievances & Appeals, and Fraud, Waste & Abuse teams, setting strategy and supervising daily operations. This exempt role interfaces with all departments, vendors, and external stakeholders with professionalism and adaptability.

You will oversee regulatory compliance, drive process improvements, and report on key metrics while leveraging data analysis to identify trends and opportunities for cost savings.

Qualifications

• B.S. degree or equivalent in a healthcare operation or related field.
• 3-5 years experience in a managed care environment.
• Strong understanding of federal and state regulations related to grievances and appeals, including CMS and state requirements.
• Experience with Medicare Advantage, ACA, employer group/TPA, MEWA products preferred.
• Demonstrated ability to lead and supervise people and teams while managing staff daily.
• Proficient in Excel with ability to analyze data and draw insights.
• Familiarity with CPT, HCPCS, ICD-10 coding is a plus.
• Excellent written and verbal communication, capable of interfacing with management and external entities.
• Ability to work in a fast-paced, high-demand environment and meet deadlines.
• Experience with SIHO systems including HSP claims system; proficient in MS Office.

Responsibilities

• Directly supervise and manage QA, Grievances & Appeals, and FWA teams with day-to-day oversight.
• Interpret and translate CMS and state regulations into practical process changes.
• Monitor and improve grievances and appeals processes for CMS/state compliance.
• Support claims and benefit configuration QA, including training staff.
• Identify and lead efforts to detect and investigate fraud, waste, and abuse (FWA).
• Review outcomes across departments to identify improvements and cost savings.
• Analyze department data in Excel to identify trends and insights.
• Manage data transfers with vendor partners and escalate issues.
• Interact with customers as needed and coordinate with SIHO Legal on special cases.
• Develop and report metrics assessing QA, FWA, and G&A program effectiveness.
• Lead compliance initiatives including SOC audits and CMS reporting.

Skills

Leadership

Regulatory knowledge

Excel

Communication

Project management

Education

B.S. degree or equivalent

Tools

HSP claims system

CMS systems

Job description

Siho Insurance Group is seeking a Director, Payment Integrity to lead the QA, Grievances & Appeals, and Fraud, Waste & Abuse teams, setting strategy and supervising daily operations. This exempt role interfaces with all departments, vendors, and external stakeholders with professionalism and adaptability.

You will oversee regulatory compliance, drive process improvements, and report on key metrics while leveraging data analysis to identify trends and opportunities for cost savings.