Director, Health Claims Audit & Recovery

The Director, Health Claims Audit & Recovery reports to the VP Finance and is responsible for providing strategic and operational leadership for the organization's health claims audit, payment integrity, and recovery functions. This position oversees the identification, validation, escalation, and recovery of health plan payment discrepancies across contracted Medicare Advantage and other payer arrangements.

The Director is accountable for developing and executing enterprise-wide audit and recovery strategies, establishing governance and performance standards, and implementing scalable processes that maximize financial recovery opportunities while ensuring payer compliance with contractual and reimbursement obligations.

This role serves as the primary business leader for payment integrity initiatives and collaborates closely with Finance, Accounting, Network & Contracting, Medical Management, Operations, and executive leadership to improve financial performance and operational effectiveness.

The Director, Health Claims Audit & Recovery reports to the VP Finance and is responsible for providing strategic and operational leadership for the organization's health claims audit, payment integrity, and recovery functions. This position oversees the identification, validation, escalation, and recovery of health plan payment discrepancies across contracted Medicare Advantage and other payer arrangements.

The Director is accountable for developing and executing enterprise-wide audit and recovery strategies, establishing governance and performance standards, and implementing scalable processes that maximize financial recovery opportunities while ensuring payer compliance with contractual and reimbursement obligations.

This role serves as the primary business leader for payment integrity initiatives and collaborates closely with Finance, Accounting, Network & Contracting, Medical Management, Operations, and executive leadership to improve financial performance and operational effectiveness.

• Develop, implement, and continuously enhance a comprehensive health claims audit and recovery strategy across all contracted health plans.
• Establish departmental goals, recovery targets, key performance indicators (KPIs), productivity standards, and quality measures aligned with organizational objectives.
• Lead the identification, analysis, validation, and recovery of health plan payment discrepancies, contractual variances, and reimbursement errors.
• Oversee the preparation, prioritization, submission, escalation, and resolution of payment reconsiderations, disputes, appeals, and recovery requests.
• Ensure timely follow-up, adjudication, collection, and reconciliation of recoverable amounts.
• Serve as the executive business owner for health plan payment integrity and recovery initiatives.
• Monitor payer compliance with contractual provisions, reimbursement methodologies, fee schedules, value-based arrangements, and plan-specific financial obligations.
• Oversee plan-specific financial adjustments, reallocations, and recovery accounting activities in accordance with contractual requirements and organizational policies.
• Collaborate with Finance, Accounting, Network & Contracting, Medical Management, Operations, and executive leadership to resolve systemic reimbursement issues and drive corrective actions.
• Design and implement scalable audit methodologies, reporting tools, analytical models, and operational workflows that support organizational growth.
• Utilize data analytics and reporting capabilities to identify recovery opportunities, payer trends, reimbursement variances, and financial risks.
• Develop and maintain executive-level reporting that communicates recovery performance, financial impact, operational effectiveness, and emerging payer issues.
• Identify and implement opportunities for automation, technology enhancements, workflow improvements, and staffing optimization to improve operational efficiency and recovery results.
• Partner with the VP Finance to establish departmental strategy, annual priorities, budget planning, performance objectives, and long-term operational direction.
• Lead, mentor,…