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.

□ 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, develop, and manage team members responsible for claims auditing, recovery operations, reporting, payer follow-up, and financial analysis.

□ Establish team structure, performance expectations, workload prioritization, accountability measures, and professional development plans.

□ Build and maintain strong working relationships with health plan partners and internal stakeholders to support recovery efforts and issue resolution.

□ Develop communication and escalation protocols with payer organizations to address disputes, recurring payment issues, and contractual compliance concerns.

□ Partner with Medical Management and clinical leadership to evaluate high-cost cases, identify utilization trends, and support recovery opportunities requiring clinical review.

□ Provide quality assurance oversight and strategic direction for audit findings, payer appeals, recovery submissions, and dispute management activities.

□ Oversee the development and delivery of routine and ad hoc reporting used for executive decision-making, financial planning, and operational improvement initiatives.

□ Evaluate team performance and staffing needs on an ongoing basis, providing coaching, mentorship, succession planning, and performance management support.

□ Consistently demonstrate behaviors that reflect the Company's commitment to exceptional customer service and stakeholder support.

□ Represent the Company professionally and in accordance with all Company policies, procedures, and standards.

□ Protect and maintain the confidentiality of patient information and ensure compliance with all HIPAA regulations and privacy requirements.

□ Perform additional duties as assigned.

□ Maintain consistent, punctual, and reliable attendance.

□ Travel as required.

□ Bachelor's Degree in Healthcare Administration, Finance, Business Administration, Accounting, or a related field preferred; equivalent combination of education and relevant experience may be considered.

□ Minimum of seven (7) to ten (10) years of progressive experience in healthcare finance, payment integrity, claims audit, payer contract analysis, revenue cycle, or related healthcare financial operations.

□ Minimum of three (3) to five (5) years of leadership experience managing teams, projects, or business functions with financial and operational accountability preferred.

□ Demonstrated experience leading claims recovery initiatives, payment variance analysis, payer dispute resolution, and financial performance reporting.

□ Experience driving cross-functional process improvement initiatives and implementing operational efficiencies preferred.

□ Working knowledge of ICD-10, CPT, HCPCS coding, provider contracting, fee schedule development, reimbursement methodologies, and healthcare financial analysis required.

□ Experience working with Medicare Advantage, managed care organizations, and value-based reimbursement arrangements strongly preferred.

□ Advanced knowledge of Medicare Advantage reimbursement methodologies, claims adjudication processes, payment integrity programs, and payer dispute resolution practices.

□ Strong understanding of managed care contracts, reimbursement policies, fee schedules, payment variance analysis, recovery accounting, and healthcare financial operations.

□ Demonstrated ability to evaluate complex claims, contractual, reimbursement, and financial issues and communicate findings to executive leadership.

□ Proficiency with claims analytics tools, revenue cycle systems, financial reporting platforms, database applications, and Microsoft Office products.

□ Strong analytical, financial, critical thinking, problem-solving, and decision-making skills.

□ Demonstrated ability to develop scalable operational processes, drive organizational change, and influence stakeholders across multiple departments.

□ Strong leadership, coaching, team development, performance management, and workforce planning capabilities.

□ Ability to manage multiple priorities and complex initiatives in a fast-paced environment while meeting deadlines.

□ High degree of accuracy, attention to detail, professionalism, integrity, and sound judgment.

□ Excellent verbal, written, presentation, and interpersonal communication skills, with the ability to communicate effectively with executives, physicians, health plan partners, and employees at all organizational levels.

□ Ability to establish and maintain collaborative working relationships with internal and external stakeholders.

□ Ability to effectively analyze large datasets, identify trends, and develop actionable business recommendations.

□ Ability to read, write, speak, and understand the English language fluently.