Director, Payment Integrity

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

Job Title: Director, Payment Integrity

Reports To: Vice President, Operations

This 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 elevate 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.