Director Payment Integrity

Pay Range

$ - $

We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well.

It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees.

We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued.

We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders.

Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

Oversee and direct programs that create a strong Payment Integrity program by developing/enhancing exiting vendor relationships and seeking new vendor relationships in alignment with the corporate strategy. Manage daily operations of the payment integrity department; lead the strategic program expansion of claims audit and recovery, including all claims editing programs. Foster and maintain collaborative relationships with providers, serving as the organization’s liaison when conducting paid claim audits.

Oversee the development of work plans to schedule and manage team resources to meet audit timelines. Ensure the integrity of the financial reporting of the department. Direct and assist team in the interpretation of health care and claims payment information. Provide subject matter expertise for corporate initiatives as it relates to audit and claims editing software areas including claims processing, contractual language, and industry standard coding conventions.

Collaborate with Executive Leadership and internal business areas to ensure effective health care delivery; develop and disseminate initiatives that improve performance as related to member and provider satisfaction, financial stability, and technology enhancements. Ensure programs, plans, and policies align with the company’s philosophy and objectives.

• Lead work teams and provide direction and technical guidance to audit and recovery staff. Provide strategic leadership and direction to management including performance management oversight and implementation of best-in-class techniques and tools.
• Provide direction to department staff regarding prioritization of areas to focus audit efforts. Develop work plans in conjunction with Division leadership to schedule and manage team resources to achieve intended audit results. Facilitate processes to continually identify new areas of opportunity including potential new and innovative vended service offerings. Responsible for meeting/exceeding budget, resource, and other commitments of the department.
• Oversee the financial integrity of the department’s…