MCO Director Payment Integrity

Role Overview

The Director of Payment Integrity Solutions is responsible for overseeing Payment Integrity edit and program strategy and performance across all ACFC lines of business and products (Medicaid, Medicare, Exchange, PBM, BH). This role ensures that implemented solutions deliver measurable value through rigorous analytics, including the use of artificial intelligence (AI), machine learning (ML), and NLP-based automation, coupled with continuous policy refinement, and strong Plan and provider stakeholder engagement. The Director leads efforts to monitor effectiveness, address operational gaps, support provider escalations, and guide ongoing improvements in payment integrity strategies and support systems. Key to the role is shifting post-payment projects, where possible, left for prospective adjudication. A key accountability includes managing the Payment Integrity Support Desk to ensure timely and high-quality issue resolution and feedback integration. This role is critical to sustaining and optimizing enterprise-wide payment accuracy and Fraud Waste and Abuse (FWA) program compliance.

Work Arrangement

• This is a 100% Remote position but you must live in EST or CST time zones

Responsibilities

Strategic Leadership & Policy Development

• Develop and manage enterprise-wide payment integrity policies and strategy across all products
• Lead cross-functional governance activities to refine and evolve payment integrity programs based on performance outcomes and regulatory changes
• Collaborate with legal, compliance, analytics, clinical policy, provider network, PI vendors, and other internal/external key stakeholders to ensure regulatory alignment and mitigate audit risk

Provider Support & Stakeholder Engagement

• Lead the development of provider engagement strategies that promote transparency and trust throughout the claims auditing process

• Act as a liaison between payment integrity operations and provider network management to address escalations and improve end-user experiences; also, represent payment integrity in escalated provider meetings
• Design and deliver training, education campaigns, and supporting materials tailored to provider audiences to clarify processes, reduce disputes, and improve outcomes

Artificial Intelligence (AI), Analytics, Reporting & Insights

• Direct development of performance dashboards, predictive analytics, and root-cause analysis to assess impact and identify areas for improvement
• Translate data findings into actionable business insights to inform strategy, training content, and policy revisions
• Use analytics to proactively identify emerging issues, support audit readiness, and drive continuous optimization
• Evaluate and implement AI-driven solutions, including machine learning, natural language processing (NLP), and predictive models to identify improper payments and reduce manual effort
• Help drive automation-first thinking across prepay and post-pay processes to reduce turnaround times and improve accuracy
• Help develop governance structure to evaluate AI vendor deliverables, ROI, and ongoing performance monitoring

Support Desk Oversight

• Lead and manage the Payment Integrity Support Desk function to ensure prompt triage and resolution of provider and internal inquiries

• Monitor service levels, identify trends in support requests, and escalate systemic issues for operational correction

• Utilize insights from support interactions to inform broader strategies, training needs, and process enhancements

Education and Experience

• At least five to ten (5 -10) experience in strategic leadership, policy development, provider relations and stakeholder engagement, and reporting and insights
• At least ten (10) or more years of experience in managed care operations/administration
• Working knowledge of CMS guidance and experience with Medicaid
• Working knowledge of payment integrity regulations and requirements
• Experience with claims adjudication platforms (Facets, QNXT, HealthRules, Peradigm/Diamond, etc.)
• Bachelor’s Degree

Other Skills:

• Ability to design and lead complex policy and product strategies that align with regulatory, operational, and financial objectives
• Demonstrated history of success in triaging, resolving, and optimizing cross-functional processes within managed care organizations
• Ability to work collaboratively with internal associates and external stakeholders and drive to expedited resolution
• Experience with vendor oversight
• Strong track record in using data analytics, reporting tools, and KPIs to drive business decisions, monitor outcomes, and support audit readiness
• Exceptional written and verbal communication skills with the ability to translate complex regulatory and technical content into user-friendly formats for providers and internal teams
• Demonstrated ability to think with the enterprise in mind
• Experience with vendor oversight and negotiating contracts

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.