Blue Cross Blue Shield of Arizona · 1 day ago
Director, Payment Integrity - Hybrid
Phoenix, AZ
Full-time
Hybrid
Senior Level, Lead/Staff
10+ years expBlue Cross Blue Shield of Arizona is dedicated to inspiring health and making it easy for individuals and businesses through various health insurance products. The Director, Payment Integrity will provide strategic leadership to ensure payment accuracy and regulatory compliance across medical and pharmacy claims, while driving operational excellence and optimizing reimbursement.
Financial ServicesHealth CareHealth InsuranceInsurance
Responsibilities
Develop and execute enterprise-wide Payment Integrity strategy aligned with organizational objectives and cost of care targets
Lead the design, implementation, and continuous improvement of payment integrity programs, including pre- and post-payment audits, recovery, and investigative functions
Establish and maintain governance structures, including cross-functional committees, to oversee payment integrity controls and policy development
Representing the organization in internal and external forums, collaborating with industry peers, regulatory bodies, and vendor partners to share best practices and drive innovation
Stay abreast of emerging trends, technologies, and regulatory shifts in the healthcare payment integrity space, proactively identifying and leveraging innovative capabilities to enhance Blue Cross Blue Shield of Arizona’s operational performance and strategic positioning
Oversee day-to-day operations, ensuring timely, accurate, and compliant claims payment and recovery activities
Direct vendor management, including contracting, performance oversight, and strategic partnerships for payment integrity solutions
Drive automation and technology adoption to enhance payment integrity processes and reporting capabilities
Lead cost-benefit analyses to determine optimal resource allocation (internal vs. outsourced functions)
Set and monitor KPIs, SMART goals, and financial targets for payment integrity initiatives
Oversee development of dashboards and scorecards to track program performance, savings, and operational improvements
Partner with actuarial, finance, and analytics teams to develop business cases, forecast savings, and evaluate ROI
Responsible for actively monitoring claims activities to ensure that identified overpayments are recouped in a timely and efficient manner
Build, lead, and develop a high-performing team, fostering a culture of accountability, innovation, and continuous improvement
Provide coaching, mentorship, and professional development opportunities
Ensure effective resource management and succession planning
Ensure adherence to regulatory, fiduciary, and customer requirements
Oversee policy and procedure development to safeguard against fraud, waste, abuse, and overpayments
Maintain up-to-date knowledge of industry standards, compliance requirements, and emerging trends
Qualification
Required
10 years of experience in Payment Integrity, Special Investigation Unit, or healthcare anti-fraud
7+ years of experience in management role
2+ years of experience in Vendor Partner Oversight; contracting and vendor management of external payment vendors and/or audit firms
Demonstrated success in developing and executing enterprise-wide strategies
Bachelor's Degree in business, statistics, healthcare administration or related field of study
Intermediate PC proficiency
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
Basic skill in word processing and presentation software
Intermediate proficiency in spreadsheet, statistical analysis, query / data mining, and business intelligence software
Advanced skill in project management
Working knowledge of classification tools (ICD, DRGs, ACGs, ETGs, etc.)
Coding Knowledge for ICD-10, CPT, or HCPCS
Risk Management Experience
Experience with Value Based Care models
Negotiation and Relationship Management
Maintain confidentiality and privacy
Communicate professionally to both internal and external customers
Analytical skills in observing and documenting processes at a detailed level
Proficiency in process improvement and business process design
Analyze and research data, propose solutions to resolve issues
Ability to use a variety of classification tools and manipulate large quantities of data
Establish, contribute and maintain a positive and productive work environment
Ability to plan, organize and manage the work of all assigned personnel
Advanced knowledge of HRIS systems, employment law, and HR regulations
Lean or Six Sigma Training
Strategic vision and enterprise leadership
Advanced analytical, financial, and project management skills
Expertise in coding, claims adjudication, and payment integrity technologies
Strong negotiation, relationship management, and communication skills
Ability to drive change, foster innovation, and build effective teams
Ability to optimize resources to ensure a cost effective operation. Includes proactively planning to move staff from one role to another as staffing needs, business priorities or workload changes
Ability to build effective teams
Ability to implement new processes and procedures
Preferred
15 years of experience in Payment Integrity, Special Investigation Unit, or healthcare anti-fraud
10 years of experience in management/leadership role
15+ years of experience in insurance or healthcare field
2+ years of experience in Operational Execution; scaling or improving claims review, fraud/waste/abuse programs, and overpayment recovery
Master's Degree in business, statistics, healthcare administration or related field of study
Advanced certifications (e.g., Healthcare Fraud Studies, Lean/Six Sigma)
Experience in large-scale program management, regulatory compliance, and data analytics
Healthcare Fraud Studies
Advanced proficiency in spreadsheet, statistical analysis, query / data mining, business intelligence software including, and data visualization tools
Cybersecurity and Data Protection practices
Regulatory Compliance
Ability to establish and maintain professional relationships with community and professional groups which reflect favorably for the department and BCBSAZ
Company
Blue Cross Blue Shield of Arizona
Blue Cross Blue Shield of Arizona is a non-profit company that offers health insurance and financial services.
1001-5000 employees
H1B Sponsorship
Blue Cross Blue Shield of Arizona 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
2024 (2)
2023 (5)
2022 (2)
2021 (1)
2020 (5)
Funding
Current Stage
Late StageLeadership Team
Pam Kehaly
President and Chief Executive Officer
Recent News
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