Remote Director, Payment Integrity & Compliance

Free resume; Columbus (IN); Híbrido; USD 130.000 - 180.000; Jornada completa

Descripción de la vacante

SIHO Insurance Services in Columbus, IN, is seeking a Director of Payment Integrity to oversee the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams. You will set strategy and supervise day-to-day operations while interfacing with all departments and external stakeholders.

Ideal candidates have a BS in healthcare operations, 3–5 years in managed care, and strong CMS/state regulatory knowledge.

Formación

• BS degree or equivalent work experience in healthcare operations.
• 3–5 years experience in a managed care environment.
• Strong understanding of federal and state regulations related to grievances and appeals (CMS and state requirements).
• Experience across Medicare Advantage, ACA, employer group/TPA, and MEWA products preferred.
• Proficient in Excel with ability to analyze data and draw actionable insights.

Responsabilidades

• Directly supervise and manage the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams, including day-to-day oversight, staffing, and performance management.
• Read and interpret federal and state regulations; translate into practical process changes.
• Monitor and improve grievances and appeals processes to ensure compliance with CMS and state requirements.
• Support the claims and benefit configuration QA program; develop and deliver training for staff.
• Lead data analysis in Excel to identify trends and opportunities; manage vendor data transfers and external inquiries.

Conocimientos

Leadership

Excel proficiency

Regulatory knowledge

Communication skills

Healthcare operations

Educación

B.S. degree or equivalent in healthcare operations

Herramientas

Excel

Word

PowerPoint

Outlook

Descripción del empleo

SIHO Insurance Services in Columbus, IN, is seeking a Director of Payment Integrity to oversee the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams. You will set strategy and supervise day-to-day operations while interfacing with all departments and external stakeholders.

Ideal candidates have a BS in healthcare operations, 3–5 years in managed care, and strong CMS/state regulatory knowledge.