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Role Description

Our Claims Payment Integrity team is seeking a Director to lead critical work that strengthens payment accuracy and drives meaningful affordability results for our members. In this role, you will have the opportunity to work with high-performing internal teams and vendor partners to enhance the accuracy of claims payments, ensure alignment with nationally recognized coding and billing standards, and play a key role in the company’s Fraud, Waste, and Abuse (FWA) program.

This position offers the opportunity to directly influence medical cost savings and support the organization’s mission of improving affordability for our customers. Expertise in using AI-enabled automation to improve operational outcomes is strongly preferred.

Although this is a remote position, quarterly travel to our Chattanooga, TN headquarters will be required. Additionally, travel to our Chattanooga headquarters will be required for final interviews.

• Overseeing payment integrity programs (claims audits, pre-pay edits, vendor products, etc.) and implementing best practices, procedures and policies for the claim payment integrity functions.
• Directing and leading payment integrity teams analyzing all evidence that provider payments are appropriate and accurately reflect billing/coding standards, company policies, provider contracts, and member benefits; identifying opportunities for fraud, waste or abuse control and prevention.
• Researching healthcare related questions as necessary to support business areas and investigations and staying abreast of current medical coding and billing issues, trends, and changes in laws/regulations.
• Maintaining and building relationships with external payment integrity vendors, various business units, Special Investigations Unit and senior management to ensure communication of critical issues in a timely manner.

Qualifications

• Bachelors degree in business, healthcare or relevant field or equivalent work experience required
• 10 years - Experience in the health care industry required
• 5 years - Experience in a leadership/management role required
• 1 year - Experience with data analytics required
• 1 year - Auditing or other relevant experience required
• 1 year - Claims or operations experience preferred

Requirements

• Excellent oral and written communication skills
• Excellent interpersonal and team building skills
• Effective and concise presentation skills

Number of Openings Available

• 1

Worker Type

• Employee