Director, Payment Integrity Strategy & Operations

Community Health Choice; Houston (TX); On-site; USD 180,000 - 240,000; Full time

Job summary

Community Health Choice is seeking a Director of Payment Integrity Strategy and Operations to lead the design, execution, and optimization of PI programs, aligning reimbursement policies with enterprise goals and improving member affordability.

You will partner with Health Care, Finance, actuarial, and external payers to develop models, dashboards, and governance, while guiding cross-functional teams through strategic roadmaps and performance management.

Qualifications

• Bachelor’s degree and 10 years of experience in reimbursement policy, provider reimbursement, and/or strategic or product development.
• Must have direct health plan experience.
• 7 years leadership experience, leading people and/or complex cross-divisional projects or programs.

Responsibilities

• Oversee day-to-day Payment Integrity operations and drive process improvements.
• Lead development of PI models and reimbursement engagement strategies.
• Set SMART goals, KPIs, and oversee cross-functional initiatives with actuarial and finance.
• Design dashboards and reporting tools to track program performance for executive leadership.
• Liaise with enterprise and external payer organizations to align strategy and cost of care efforts.

Skills

Strategic leadership

Program management

Performance measurement

Cross-functional collaboration

Education

Bachelor's degree

Job description

The Director of Payment Integrity Strategy and Operations provides strategic leadership and oversight in the design, execution, and optimization of Payment Integrity (PI) programs focused on enhancing payment accuracy and driving member affordability. This role serves as a key liaison for all reimbursement policy and PI initiatives, helping to align cost of care goals, drive ideation and prioritization, establish governance for reimbursement policies, and coordinate performance management across the program. This leader partners closely with stakeholders in Health Care, Finance, and external payer organizations to identify, develop, and implement innovative and effective PI strategies.

JOB SPECIFICATIONS AND CORE COMPETENCIES

35% Operational Oversight & Performance Management

• Manages day-to-day PI operations, ensuring execution of process improvements and program redesigns.
• Oversees team performance, implements internal evaluations, and coordinates with vendors and solution partners.
• Guides the development of new PI models and reimbursement engagement strategies

30% Strategic Leadership & Program Development

• Develops and drives the overall strategy for Payment Integrity (PI), aligning cost of care initiatives with enterprise goals.
• Sets SMART goals, leads ideation and vetting processes, and establishes KPIs to monitor and evaluate success.
• Partners with actuarial and finance teams to develop business cases and manage cross-functional initiatives.
• Drives organizational change, facilitates execution of strategic roadmaps, and aligns project milestones to overall business goals.
• Designs dashboards and reporting tools to track program performance and communicate insights to executive leadership.
• Leads internal and external evaluations and aligns department metrics with corporate objectives and financial strategies.

25% Reimbursement Policy & Governance

• Leads the development and management of reimbursement policies.
• Establishes and facilitates Reimbursement Policy Governance Committees for Commercial and Medicare lines of business.
• Communicates updates, solicits feedback, and documents approvals and concerns

5% Enterprise & External Collaboration

• Serves as a liaison and thought leader for PI across the enterprise and with external organizations and other payer organizations.
• Leads cross-functional meetings and governance committees to communicate strategy, share insights, and align on cost of care efforts.

5% Other Duties Assigned

QUALIFICATIONS

Education/Specialized Training/Licensure: Bachelor’s degree and 10 years of experience in reimbursement policy, provider reimbursement, and/or strategic or product development

Work Experience (Years and Area): Must have direct health plan experience Previous experience directly with business case development, financial and market analysis and/or process redesign

Management Experience (Years and Area): 7 years leadership experience, leading people and/or complex cross-divisional projects or programs