Program Integrity - Ideation and Analytics

The AVP of Program Integrity will lead strategy, execution, and continuous improvement of audit concepts in healthcare payment integrity, focusing on payer-side expertise, clinical and coding knowledge, and translating policies into scalable audit logic.

Location: Remote (US)

Responsibilities

• Direct multi-disciplinary PI teams including Ideation SMEs, Pricing Analysts, auditors, and program integrity staff.
• Build and scale high-yield pre-pay and post-pay audit operations delivering measurable savings and ROI.
• Establish centralized workflows, SOPs, quality assurance programs, and performance dashboards.
• Lead development of innovative audit concepts across data mining and clinical review.
• Use analytics to uncover trends, patterns, atypical billing behavior, and outlier providers.
• Translate regulatory and medical policy changes into proactive PI strategies and editable audit logic.
• Interpret complex Medicaid, Medicare, and commercial reimbursement rules.
• Partner with the pricing team to convert pricing guidelines into automated pricer logic within PI tools.
• Ensure accuracy, compliance, and scalability of contract audit methodologies.
• Provide strategic oversight of SIU/FWA functions including investigators, managers, and directors.
• Drive enterprise-wide FWA risk assessments and ensure compliance with federal/state regulations.
• Build relationships with industry bodies (BCBSA, NHCAA, law enforcement, regulatory agencies).
• Serve as a PI subject matter expert in client discussions, sales cycles, and go-to-market strategy.
• Understand client goals, identify opportunity areas, and co-create PI roadmaps.
• Monitor KPIs for client engagement, satisfaction, and revenue growth.
• Oversee PI vendor relationships including claims editing partners, overpayment recovery partners, and audit vendors.
• Ensure vendor staff effectiveness, compliance, and alignment with enterprise PI strategy.
• Develop reporting metrics to track medical cost savings, team productivity, quality, and ROI.
• Drive long-term performance improvement; replicate and scale successful PI concepts.

Requirements

• 10+ years of healthcare experience in Payment Integrity, SIU/FWA, coding compliance, and audit operations.
• Exceptional Executional Skills – meet numbers/goals and objectives.
• Demonstrated success building centralized PI programs (pre-pay, post-pay, policy, edits, chart review).
• Strong experience with payer environments (Medicaid, Medicare, Commercial) and audit vendors.
• Expertise in developing audit concepts, pricing logic, and regulatory interpretation.
• Proven leadership of teams of 20–30+ investigators, SMEs, analysts, and auditors.
• Certifications such as AHFI and CPC (highly preferred).
• Bachelor’s degree in Criminal Justice, Finance, Healthcare Administration, or related field.

Additional Information

• Client-Centric Orientation: Deep understanding of payer needs and ability to architect PI solutions that drive measurable value