New

Director, Payment Integrity

HMSA
United States, Hawaii, Honolulu
818 Ke’eaumoku Street (Show on map)
Sep 17, 2025
Strategic Leadership: Develop and execute the organization's payment integrity strategy, aligning with enterprise cost containment goals. Oversee the design and implementation of pre-pay and post-pay review processes. Operational Oversight: Manage payment integrity programs and functions, including first pass and second pass code editors, data analytics, provider audit, and subrogation. Ensure accurate identification and resolution of claim overpayments. Collaborate with claims, provider network, compliance, and finance departments to improve payment accuracy. Analytics & Reporting: Direct the development of analytical models and reporting dashboards to identify patterns of improper payment. Monitor key performance indicators (KPIs) such as savings achieved, recovery rates, and audit cycle times. Compliance & Governance Ensure compliance with CMS, State Medicaid, ERISA, and commercial regulations around claims adjudication and payment practices. Partner with Compliance, Legal, and SIU (Special Investigations Unit) to manage regulatory audits and oversight. Vendor & Relations: Manage relationships with third-party payment integrity vendors, ensuring contract compliance and performance metrics are met. Stay current with changes in laws, regulations, and industry best practices related to claims management Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid