Director, Payment Integrity (Fully Remote)

SIHO Insurance Services; United States; Remote; USD 120,000 - 150,000; Full time

Job summary

SIHO Insurance Services seeks an exempt leader who will report to the Vice President of Operations and set strategy for QA, Grievances & Appeals, and FWA teams. You will manage day-to-day operations across SIHO departments, guiding regulatory interpretation to ensure CMS and state compliance.

You will oversee staffing, performance management, and vendor data transfers, driving quality assurance programs and compatibility with Medicare Advantage, ACA, and evolving state regulations.

Qualifications

• Requires a B.S. degree or equivalent healthcare operations experience with 3–5 years in managed care.
• Proficiency in Excel and strong understanding of Medicare Advantage, ACA, and state insurance regulations.

Responsibilities

• Oversee staffing, performance management, and regulatory interpretation to maintain CMS and state compliance.
• Monitor FWA trends, manage vendor data transfers, and support claims quality assurance programs.

Skills

Regulatory interpretation

Staffing & performance management

CMS regulations

Medicare Advantage knowledge

Analytical skills

Education

Bachelor's degree or equivalent healthcare operations experience

Tools

Excel

CMS Part C Reporting

SOC audits

Job description

• This exempt position reports to the Vice President, Operations and sets strategy for QA, Grievances & Appeals, and FWA teams.
• This role manages day-to-day operations and interacts with all SIHO departments, external stakeholders, and customers.

Key Responsibilities:

• Oversee staffing, performance management, and regulatory interpretation to maintain CMS and state compliance.
• Monitor FWA trends, manage vendor data transfers, and support claims quality assurance programs.

Qualifications:

• Requires a B.S. degree or equivalent healthcare operations experience with 3-5 years in managed care.
• Proficiency in Excel and strong understanding of Medicare Advantage, ACA, and state insurance regulations.

Compliance:

• Lead compliance initiatives including SOC audits, CMS Part C Reporting, and ODAG.
• Work with SIHO Legal and external parties including CMS and law enforcement on special cases.

SIHO Insurance Services

SIHO Insurance Services provides health insurance administration and related services, focusing on payment integrity and regulatory compliance. The company operates in a managed care environment and emphasizes collaboration, professionalism, and adaptability among its employees.