This exempt role reports to the Vice President, Operations at SIHO Insurance Services. The Director, Payment Integrity oversees three teams: Quality Assurance, Grievances & Appeals, and Fraud, Waste & Abuse. The position involves both setting departmental strategy and directly supervising day-to-day operations. The role requires interaction with all SIHO departments as well as external stakeholders, vendors, and customers, with professionalism at all levels and the ability to shift quickly between multiple high-priority items. Key duties include directly supervising and managing the three teams, overseeing daily operations, staffing, and performance management; reading, researching, and interpreting federal and state regulations on grievances and appeals, and translating those requirements into practical process changes; continuously monitoring and improving grievances and appeals processes to maintain compliance with CMS and state regulatory requirements; supporting the claims and benefit configuration quality assurance program, including developing and delivering staff training; staying current on emerging fraud, waste, and abuse trends and proactively leading identification and investigation efforts; reviewing results across all three departments to identify process improvement initiatives and cost savings opportunities; analyzing department and operational data in Excel to find trends and actionable insights; managing data transfers with vendor partners, meeting with vendors regularly to ensure processes function as intended, and escalating potential issues; interacting directly with customers as needed; collaborating with SIHO Legal and key leadership on special cases and external inquiries from CMS, the Indiana Department of Insurance, law enforcement, and others; developing, maintaining, and reporting statistical measurements on the effectiveness of the QA, FWA, and G&A programs; and leading or supporting corporate and departmental compliance initiatives including SOC audits, CMS Part C Reporting and ODAG, and others as assigned. Minimum qualifications: a B.S. degree or equivalent work experience in healthcare operations; 3-5 years of experience in a managed care environment; strong understanding of federal and state regulations related to grievances and appeals, including CMS and state Department of Insurance requirements; experience across Medicare Advantage, ACA, employer group/TPA, and MEWA products preferred; demonstrated ability to lead and manage people and teams while directly supervising staff daily; proficiency in Excel with the ability to analyze data and draw actionable insights; thorough understanding of medical and health plan terminology, with familiarity in CPT, HCPCS, and ICD-10 coding a plus; excellent written and verbal communication skills for interacting with all management levels and external entities, vendors, and customers; ability to work at a self-directed pace in a changing, fast-paced, high-demand environment, adapting quickly between competing high-priority items; ability to work under tight deadlines; experience with SIHO systems including the HSP claims system; and proficiency in Microsoft Office suite products including Word, Excel, PowerPoint, and Outlook. All positions are subject to change based on business needs.

Director Payment Integrity

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