Director, Payment Integrity: Build & Lead the Program

Capital Rx; Charlotte (NC); Hybrid; USD 172,000 - 215,000; Full time

Job summary

Judi Health is seeking a Director of Payment Integrity to build and lead our program from inception. You will establish policies, develop prepay edit logic, and drive cost savings across prepay and post-pay claims.

This strategic yet hands-on role requires clinical coding expertise and leadership to scale the function. In this hybrid role, you will partner with Compliance, Legal, Product, and Claims Operations to implement robust edits, DRG validation, and post-pay reviews, while guiding a

Qualifications

• Bachelor's degree and 10+ years in payment integrity or related field.
• Deep subject matter expertise in commercial health plan payment integrity.
• Experience designing and maintaining prepay edit rules.
• Knowledge of CPT, ICD-10-CM/PCS, HCPCS and coding guidelines.

Responsibilities

• Define reimbursement policies and build prepay edit libraries from the ground up.
• Lead program build-out including DRG validation and itemized bill review.
• Improve claims accuracy and cost savings across prepay and post-pay channels.
• Ensure compliance with commercial insurance regulations and vendor evaluations.

Skills

Payment integrity

Healthcare claims analysis

Prepay edit design

Analytical leadership

Education

Bachelor's degree in a related field

Tools

SQL

Business Intelligence

Job description

Judi Health is seeking a Director of Payment Integrity to build and lead our program from inception. You will establish policies, develop prepay edit logic, and drive cost savings across prepay and post-pay claims.

This strategic yet hands-on role requires clinical coding expertise and leadership to scale the function. In this hybrid role, you will partner with Compliance, Legal, Product, and Claims Operations to implement robust edits, DRG validation, and post-pay reviews, while guiding a