Lead, Payment Integrity Innovation & Audit Programs

View Moreicons; United States; Remote; USD 120,000 - 160,000; Full time

Job summary

Sagility in the United States is seeking a Manager, Payment Integrity Program Development & Innovation to lead a team of experts focused on auditing healthcare overpayments and developing advanced recovery strategies.

You will partner with clinical, analytics, appeals, and client-facing teams to design concepts, refine claim selection, and scale innovative audit solutions across inpatient, outpatient, professional, and DME services. Remote work from the USA is supported.

Qualifications

• Bachelor’s degree in Nursing or related field.
• Minimum of 5 years of healthcare Payment Integrity experience.
• Minimum of 3 years of leadership experience managing audit, coding, clinical, payment integrity, or SME teams.
• Strong knowledge of healthcare reimbursement methodologies and claims adjudication.
• Experience collaborating with analytics, operations, and appeals teams.

Responsibilities

• Lead, mentor, and develop a team of Subject Matter Experts responsible for complex audit program design and implementation.
• Foster a culture of accountability, collaboration, innovation, and continuous improvement.
• Establish performance expectations and monitor team productivity, quality, and operational effectiveness.
• Support recruitment, onboarding, professional development, and succession planning initiatives.
• Develop and maintain a portfolio of complex payment integrity audit concepts and recovery initiatives.
• Identify emerging overpayment risks and reimbursement vulnerabilities across multiple healthcare claim types.
• Evaluate opportunities based on financial impact, operational feasibility, recovery potential, and client value.
• Collaborate with internal stakeholders to prioritize and implement new audit programs.
• Partner with analytics and technology teams to design, validate, and optimize claim selection methodologies and audit algorithms.
• Define business requirements and selection criteria for complex audit programs.
• Monitor audit performance and continuously refine targeting strategies to improve recovery yield and audit accuracy.
• Evaluate program metrics, including hit rates, recovery rates, overturn rates, and return on investment.
• Provide subject matter expertise on healthcare reimbursement methodologies, payment policies, coding guidelines, and industry best practices.
• Ensure audit concepts and methodologies comply with applicable regulatory, contractual, and operational requirements.
• Serve as an escalation point for complex audit findings, provider disputes, and appeals support activities.
• Maintain current knowledge of Medicare, Medicaid, Commercial, and Managed Care reimbursement methodologies.
• Partner with Operations, Clinical, Appeals, Product, Analytics, Compliance, and Client Services teams to support successful program implementation.
• Participate in client-facing discussions related to audit methodologies, findings, performance metrics, and program strategy.
• Support sales, implementation, and proposal efforts by providing subject matter expertise and audit program recommendations.
• Contribute to strategic initiatives that enhance payment integrity capabilities and client outcomes.

Skills

Leadership

Audit program design

Claims analytics

Regulatory compliance

Stakeholder collaboration

Team development

Education

Bachelor’s degree in Nursing or related field

Tools

Audit platforms

Claims analytics tools

Job description

Sagility in the United States is seeking a Manager, Payment Integrity Program Development & Innovation to lead a team of experts focused on auditing healthcare overpayments and developing advanced recovery strategies.

You will partner with clinical, analytics, appeals, and client-facing teams to design concepts, refine claim selection, and scale innovative audit solutions across inpatient, outpatient, professional, and DME services. Remote work from the USA is supported.