Director Payment Integrity

Job Title: Director, Payment Integrity Reports To: Vice President, Operations This is an exempt position reporting to the Vice President, Operations. The Director of Payment Integrity is responsible for the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse teams. This role functions as both the director setting strategy for these departments and the direct supervisor managing day to day operations. This position interfaces with all departments of SIHO as well as external stakeholders, vendors, and customers. The ability to interact with all levels of SIHO staff and external parties with a high level of professionalism, while adapting quickly between multiple high priority items, is essential. Brief Description of Duties: Directly supervise and manage the Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse 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 escalate potential issues as they arise Interact directly with customers as needed Work with SIHO Legal and key leadership on special cases