Director, Payment Integrity

The Director, Payment Integrity provides strategic leadership and oversight for all Payment Integrity functions, ensuring payment accuracy, regulatory compliance, and cost containment across medical and pharmacy claims. This role sets the vision and strategy for payment integrity programs, drives operational excellence, and partners across the enterprise to optimize reimbursement, prevent fraud/waste/abuse, and improve member affordability. The Director is accountable for developing and executing initiatives that deliver measurable savings, enhance process efficiency, and support organizational goals. This role is responsible for the performance and oversight of all Claims Payment Integrity functions and processes. These functions and processes serve to ensure appropriate payment is made for eligible members, according to contractual terms, not in error, and free of wasteful and abusive practices for all medical/pharmacy claims. This position will have accountability for leading a diverse team focused on a variety of Payment Integrity tasks including; claims payment and recovery activities, pre/post payment audit, and investigative functions. Functions of this team provide capabilities to meet regulatory, fiduciary and customer requirements and expectations to ensure over/underpayments risk are minimized and that to the extent payment issues are identified, they are remediated quickly.