Director, Payment Integrity

MyTruAdvantage; Columbus (IN); Hybrid; USD 110,000 - 150,000; Full time

Job summary

SIHO is seeking a Director of Payment Integrity to lead QA, Grievances & Appeals, and Fraud, Waste & Abuse teams in Columbus, IN. This role shapes strategy and directly supervises day-to-day operations, partnering with multiple departments and external stakeholders.

The ideal candidate holds a B.S. or equivalent, 3–5 years in managed care, deep regulatory knowledge (CMS, state requirements), and proven people leadership, with strong Excel and communication skills to drive compliance and

Qualifications

• B.S. degree or equivalent healthcare operations experience.
• 3–5 years in a managed care environment.
• Strong knowledge of CMS and state regulations.

Responsibilities

• Directly supervise QA, Grievances & Appeals, and Fraud, Waste & Abuse teams.
• Translate regulatory requirements into practical, actionable process changes.
• Continuously monitor and improve grievances and appeals processes for compliance.
• Lead data analysis to identify trends and drive improvements.
• Collaborate with vendors and external stakeholders; interface with SIHO leadership.

Skills

Leadership

Regulatory knowledge

Data analysis

Communication

Project management

Education

Bachelor's degree

Tools

Excel

PowerPoint

Outlook

HSP claims system

Job description

# Director, Payment IntegrityHot Job417 Washington Street - Columbus, IN 47201## OverviewPosition TypeFull TimeJob ShiftDay ShiftTravel PercentageNo TravelCategoryInsurance## Description**Job Title: Director, Payment Integrity****Reports To:** Vice President, OperationsThis is an exempt position reporting to the Vice President, Operations. The Director of Payment Integrity is responsible for the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams. This role functions as both the director setting strategy for these departments and the direct supervisor managing day to day operations. This position interfaces with all departments of SIHO as well as external stakeholders, vendors, and customers. The ability to interact with all levels of SIHO staff and external parties with a high level of professionalism, while adapting quickly between multiple high priority items, is essential.**Brief Description of Duties:*** Directly supervise and manage the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams, including day to day oversight, staffing, and performance management* Read, research, and interpret federal and state regulations governing grievances and appeals, and translate regulatory requirements into practical, actionable process changes* Continuously monitor and improve grievances and appeals processes to ensure ongoing compliance with CMS and state regulatory requirements* Support the claims and benefit configuration quality assurance program, including developing and delivering training and education for staff* Stay current on emerging fraud, waste, and abuse trends and lead efforts to proactively identify and investigate potential FWA* Review results across all three departments and identify process improvement initiatives and cost savings opportunities* Analyze department and operational data in Excel to identify trends and draw actionable insights* Manage data transfers with vendor partners, meet with vendors regularly to ensure processes are working as intended, and escalate potential issues as they arise* Interact directly with customers as needed* Work with SIHO Legal and key leadership on special cases and external inquiries from CMS, the Indiana Department of Insurance, law enforcement, and others* Develop, maintain, and report statistical measurements assessing the effectiveness of the QA, FWA, and G&A programs* Lead or support key corporate and departmental compliance initiatives, including SOC audits, CMS Part C Reporting and ODAG, and others as assigned**Minimum Skills Requirement:*** B.S. degree or equivalent work experience in a healthcare operation* 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 Department of Insurance requirements* Experience across Medicare Advantage, ACA, employer group/TPA, and MEWA products preferred* Demonstrated ability to lead and manage people and teams, while also directly supervising staff on a daily basis* Proficient in Excel with the ability to analyze data and draw actionable insights* Thorough understanding of medical and health plan terminology; familiarity with CPT, HCPCS, and ICD-10 coding a plus* Excellent written and verbal communication skills, with the ability to clearly communicate with all levels of management as well as external entities, vendors, and customers* Ability to work successfully at a self-directed pace in a changing, fast-paced, high demand environment, adapting quickly between competing high priority items* Ability to work successfully under tight deadlines* Experience with SIHO systems including the HSP claims system* Proficient in Microsoft Office suite products including Word, Excel, PowerPoint, and Outlook*All positions are subject to change based on the needs of the business.*