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Director of Claims Payment Payment Integrity Operations

Gravie, Inc.

Job Overview

Location

Remote

Job Type

Full-time

Full Job Description

📋 Description

• Own and continuously refine the end-to-end lifecycle of claims payment and payment integrity at Gravie, ensuring every dollar is adjudicated accurately, paid on time, and recovered when appropriate. You will architect scalable workflows that balance speed, compliance, and member experience.
• Design and deploy data-driven strategies that detect and prevent fraud, waste, and abuse before money leaves the door. This includes building predictive models, exception-based reporting, and real-time monitoring dashboards that surface anomalies for rapid intervention.
• Lead a high-performing, fully remote team of analysts, auditors, and recovery specialists. Set clear KPIs, coach for growth, and cultivate a culture where curiosity, accountability, and innovation are the norm. You’ll conduct weekly huddles, quarterly business reviews, and annual talent assessments to keep the team sharp and engaged.
• Manage a portfolio of third-party vendors—payment integrity partners, subrogation firms, data-mining vendors, and clearinghouses—ensuring SLAs are met, contracts are optimized, and savings are maximized. You will negotiate renewals, hold quarterly QBRs, and sunset underperforming relationships without missing a beat.
• Partner cross-functionally with Claims Operations, Clinical, Finance, Legal, and Product to translate complex regulatory requirements into elegant operational solutions. Whether it’s COB, MSP, or new state mandates, you’ll translate legalese into executable playbooks that protect Gravie and delight members.
• Build and maintain a robust control environment that satisfies SOC 1, SOC 2, CMS, and state DOI audits. You’ll own policy documentation, risk assessments, and remediation plans, ensuring every control is tested, evidenced, and continuously improved.
• Drive the roadmap for payment integrity technology—evaluating RPA, AI/ML platforms, and next-gen analytics tools. You will write business cases, manage pilots, and lead change management so new tech lands smoothly and delivers measurable ROI.
• Establish and track a balanced scorecard of financial, operational, and quality metrics: auto-adjudication rates, overpayment recovery dollars, clean claim rates, appeal overturn rates, and member NPS. You’ll present insights to the executive team monthly and adjust tactics in real time.
• Champion a culture of continuous improvement by running Kaizen events, A/B tests, and root-cause analyses. Celebrate wins loudly and turn misses into learning moments that propel the organization forward.
• Serve as the subject-matter expert for all things payment integrity, representing Gravie in industry forums, client calls, and regulatory roundtables. Your thought leadership will shape not only Gravie’s future but the broader healthcare ecosystem.

🎯 Requirements

• Bachelor’s degree or equivalent experience plus 8+ years in healthcare claims and payments
• 3+ years of direct team management experience in a remote or hybrid environment
• Deep, hands-on expertise in payment integrity disciplines: subrogation, COB, data mining, credit balance recoupment, and fraud/waste/abuse detection
• Proven track record of using data analytics to drive strategic decisions and measurable financial outcomes
• Demonstrated success managing third-party vendors to contractual SLAs and savings targets

🏖️ Benefits

• Competitive base salary of $118,275–$197,125 plus annual bonus and stock options
• Flexible PTO, 16 weeks paid parental leave, and 1 week paid paw-ternity leave
• Comprehensive health and wellness benefits including alternative medicine coverage
• 401(k) program, education reimbursement, cell phone reimbursement, and transportation perks

Skills & Technologies

Remote

Degree Required

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Gravie, Inc.

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About Gravie, Inc.

Gravie is a Minneapolis-based health benefits company founded in 2013 that designs and administers employer-sponsored health plans. Its flagship product, Comfort, is a zero-deductible plan combining self-funding, stop-loss insurance and direct provider contracts to give employees first-dollar coverage while controlling employer costs. The company also offers Individual Market solutions, ICHRA administration and a marketplace for supplemental benefits. Gravie serves mid-market and enterprise clients through its technology platform and member support services, aiming to simplify healthcare purchasing and reduce financial barriers for employees.

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