Director, Payment Integrity & Compliance

Resumonk; United States; Remote; USD 120,000 - 180,000; Full time

Job summary

Resumonk seeks a Director of Payment Integrity to lead the QA, Grievances & Appeals, and Fraud, Waste & Abuse teams, shaping strategy and overseeing daily operations. The role interfaces with all SIHO departments, external vendors, and customers to ensure effective program execution.

The position requires interpreting federal/state regulations, ensuring CMS/state compliance, delivering staff training, and using Excel analytics to identify trends and cost-saving improvements while maintaining

Qualifications

• Bachelor's degree or equivalent in healthcare operation
• 3-5 years in a managed care environment
• Strong understanding of federal and state regulations related to grievances and appeals
• Experience with Medicare Advantage/ACA beneficial

Responsibilities

• Directly supervise and manage the QA, G&A, and FWA 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 escalation 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

Skills

Team leadership

Regulatory compliance

Data analysis (Excel)

Stakeholder communication

Healthcare payer experience

Education

B.S. degree or equivalent in healthcare operation

3-5 years in a managed care environment

Tools

HSP claims system

Microsoft Office (Excel, PowerPoint, Word)

Job description

Resumonk seeks a Director of Payment Integrity to lead the QA, Grievances & Appeals, and Fraud, Waste & Abuse teams, shaping strategy and overseeing daily operations. The role interfaces with all SIHO departments, external vendors, and customers to ensure effective program execution.

The position requires interpreting federal/state regulations, ensuring CMS/state compliance, delivering staff training, and using Excel analytics to identify trends and cost-saving improvements while maintaining