Director Claims Payment Integrity

📋 Description

• • Lead and oversee comprehensive payment integrity programs, encompassing claims audits, pre-pay edits, and the strategic management of vendor products, ensuring the implementation of industry-leading best practices, robust procedures, and effective policies across all claim payment integrity functions.
• • Direct and guide dedicated payment integrity teams in the meticulous analysis of all evidence to confirm that provider payments are appropriate, accurately reflect established billing and coding standards, align with company policies, adhere to provider contracts, and comply with member benefits. This includes proactively identifying and addressing opportunities for fraud, waste, and abuse (FWA) control and prevention.
• • Conduct in-depth research into healthcare-related questions as necessary to provide critical support to various business areas and investigations. Maintain a proactive stance in staying abreast of current medical coding and billing issues, emerging trends, and evolving changes in healthcare laws and regulations to ensure compliance and optimize payment accuracy.
• • Cultivate and maintain strong, collaborative relationships with external payment integrity vendors, diverse internal business units, the Special Investigations Unit (SIU), and senior management. Ensure timely and transparent communication of critical issues, findings, and strategic recommendations to all relevant stakeholders.
• • Drive the strategic direction and operational execution of initiatives aimed at enhancing payment accuracy, reducing healthcare costs, and improving overall affordability for members. This involves leveraging data analytics and potentially AI-enabled automation to achieve superior operational outcomes.
• • Develop and implement innovative strategies to detect and prevent fraudulent, wasteful, or abusive claims, thereby safeguarding the company's financial integrity and protecting member resources.
• • Collaborate with cross-functional teams, including but not limited to, claims processing, provider relations, legal, and compliance, to ensure a unified approach to payment integrity and FWA prevention.
• • Monitor key performance indicators (KPIs) and metrics related to payment integrity operations, providing regular reports and analyses to senior leadership to inform strategic decision-making and identify areas for continuous improvement.
• • Ensure that all payment integrity activities are conducted in compliance with federal and state regulations, industry standards, and company policies.
• • Foster a culture of continuous learning and development within the payment integrity team, encouraging professional growth and the adoption of new technologies and methodologies.
• • Play a pivotal role in the company’s Fraud, Waste, and Abuse (FWA) program, contributing expertise and leadership to its ongoing effectiveness and evolution.
• • Contribute to the company’s mission of improving affordability for its customers by ensuring that payments are accurate and appropriate, thereby minimizing unnecessary costs.
• • Evaluate and select new payment integrity vendors and technologies, negotiating contracts and overseeing their performance to ensure optimal results and return on investment.
• • Provide expert guidance and support on complex claims payment issues, acting as a subject matter expert for internal teams and external partners.
• • Champion the use of advanced analytics and AI-enabled automation to identify complex patterns of FWA and payment discrepancies, driving efficiency and effectiveness in the payment integrity process.
• • Prepare and deliver compelling presentations to senior leadership, outlining program performance, strategic initiatives, and recommendations for future action.
• • Manage budgets and resources effectively to ensure the efficient and successful operation of the payment integrity department.
• • Stay informed about the competitive landscape and best practices in payment integrity across the healthcare industry, incorporating relevant insights into the company's strategy.
• • Ensure that all processes and procedures are well-documented and readily accessible to relevant personnel.
• • Uphold the company's commitment to ethical conduct and compliance in all aspects of payment integrity operations.