Director, Payment Integrity & Claims Quality

Judi Health, LLC; New York (NY); Hybrid; USD 206,000 - 258,000; Full time

Job summary

Judi Health, LLC in New York, NY is seeking a Director of Payment Integrity to build and lead Judi Health's payment integrity program from inception, establishing the infrastructure, processes, and team to ensure claims are paid correctly, compliantly, and efficiently across our commercial plan population.

This strategic, hands-on leadership role will define reimbursement policies, design prepay edit logic, and develop and maintain payment integrity functions.

Qualifications

• Bachelor's degree and a minimum of 10 years of progressive experience in payment integrity, healthcare claims, or a related field.
• Deep subject matter expertise in commercial health plan payment integrity, including prepay edit development and claims adjudication.
• Experience developing or managing prepay edit programs, including rules logic design, implementation, and maintenance.
• Strong working knowledge of commercial billing guidelines, CPT, ICD-10-CM/PCS, HCPCS, revenue codes, and claim editing logic (e.g., NCCI, MUE, RVU-based edits).
• Proven track record of generating medical cost savings through payment integrity initiatives.
• Experience operating in a player-coach capacity, comfortable doing hands-on technical work while setting strategic direction.
• Exceptional analytical, communication, and leadership skills.
• Professional coding credential (CPC, CCS, or equivalent).

Responsibilities

• Define, publish and maintain Judi Health’s reimbursement policies.
• Work with clients to ascertain client-specific set of reimbursement policies.
• Design and develop Judi Health's prepay edit library from the ground up, leveraging industry-standard logic and commercial payer best practices
• Implement, test, and validate prepay edits across claim types including professional, facility, and ancillary
• Establish edit maintenance workflows to keep rules current with coding updates (CPT, ICD-10, HCPCS), payer policy changes, and regulatory requirements
• Identify appropriate sources for claim edit content (e.g. ACS, CMS, AMA) and work with product team to establish regular updates and translation of codes to those needed in rule production.
• Define the long‑term payment integrity program strategy, including phased expansion into post‑pay review, DRG audits, and itemized bill review
• Lead 'buy vs. build' decision‑making, evaluating vendor solutions against internal development options based on cost, capability, and scalability
• Identify and address claim payment leakage across prepay and post‑pay channels, with accountability for measurable medical cost savings
• Analyze claims data to surface patterns of billing errors, upcoding, unbundling, duplicate billing, and other improper payment risks
• Develop and oversee DRG validation audit processes, ensuring inpatient claims are billed at the appropriate severity and complexity
• Build and manage an itemized bill review program for high‑dollar inpatient and outpatient claims
• Establish and monitor KPIs for edit performance, savings yield, false positive rates, and provider dispute outcomes
• Ensure all payment integrity activities comply with applicable commercial insurance regulations
• Monitor changes in commercial payer policy, coding guidelines, and regulatory requirements and translate them into timely program adjustments
• Partner with Compliance and Legal to ensure FWA activities meet regulatory standards and documentation requirements
• Maintain audit‑ready documentation for all edit logic, policy rationale, and program decisions
• Serve as the organizational subject matter expert on payment integrity, educating internal stakeholders on program rationale, edit logic, and savings impact
• Collaborate with Product, Claims Operations, Medical Management, Provider Relations, Finance, and Technology to integrate payment integrity into end‑to‑end claim workflows
• Partner with analytics and technology teams to define data requirements, reporting infrastructure, and tooling that support program scale
• Represent payment integrity in provider dispute resolution, escalations, and cross‑functional issue management
• Develop and execute a staffing plan to grow the payment integrity team as program scope expands
• Recruit, hire, and develop payment integrity professionals including clinical coders, auditors, and analysts
• Foster a collaborative, high‑performance team culture grounded in accuracy, accountability, and continuous improvement
• Serve as a mentor and technical resource for team members, building internal coding and audit expertise

Skills

Payment integrity

Claims adjudication

Leadership

Analytics

Communication

Problem solving

Education

Bachelor's degree in a related field

CPC / CCS or equivalent

Tools

SQL

Data querying tools

Business intelligence platforms

Job description

Judi Health, LLC in New York, NY is seeking a Director of Payment Integrity to build and lead Judi Health's payment integrity program from inception, establishing the infrastructure, processes, and team to ensure claims are paid correctly, compliantly, and efficiently across our commercial plan population.

This strategic, hands-on leadership role will define reimbursement policies, design prepay edit logic, and develop and maintain payment integrity functions.