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AmeriHealth Caritas · 2 days ago

MCO Director Payment Integrity

United States

Full-time

Remote

Director/Executive

10+ years exp

AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience delivering comprehensive, outcomes-driven care. The Director of Payment Integrity Solutions is responsible for overseeing payment integrity strategies and performance across all lines of business, ensuring solutions deliver measurable value through analytics and stakeholder engagement.

Health CareInformation Technology

H1B Sponsor Likely

Responsibilities

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

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

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

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

Qualification

Payment Integrity StrategyArtificial Intelligence (AI)Machine Learning (ML)Natural Language Processing (NLP)Managed Care OperationsClaims Adjudication PlatformsData AnalyticsStakeholder EngagementPolicy DevelopmentVendor OversightCommunication Skills

Required

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

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

Benefits

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.

Company

AmeriHealth Caritas

Glassdoor3.4

AmeriHealth Caritas is the health care solutions provider for those in most need and the chronically ill.

Founded in 1982

Philadelphia, Pennsylvania, USA

10001+ employees

http://www.amerihealthcaritas.com

H1B Sponsorship

AmeriHealth Caritas has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (18)

2024 (17)

2023 (12)

2022 (14)

2021 (4)

2020 (11)