Job description
Position Summary:
We are seeking a Quality Director/Manager to build and oversee the quality and compliance framework for our Payment Integrity (PI) operations. This role will partner closely with the Delivery Manager and Business Analyst to ensure disciplined operations, accurate execution, and adherence to regulatory and payer standards. The Quality Director/Manager will establish audit routines, quality checkpoints, error tracking, and remediation plans while monitoring operational goals.
Responsibilities:
- Develop and lead a comprehensive quality assurance and compliance program for PI operations (DRG review, HBA, COB, IBR, data mining, edit engines).
- Establish and manage audit routines, quality checks, and error tracking mechanisms.
- Implement remediation plans to address systemic issues and drive continuous improvement.
- Ensure compliance with CMS guidelines, NCCI edits, LCD/NCD policies, payer rules, and internal standards.
- Partner with the Delivery Manager to enforce production discipline and reporting controls.
- Collaborate with the Business Analyst to document quality workflows, SOPs, and acceptance criteria.
- Analyze quality metrics and produce dashboards/reports for leadership on accuracy, compliance, and error trends.
- Serve as the compliance subject matter expert, keeping the team current on regulatory and payer policy updates.
- Lead training sessions and workshops to improve staff accuracy, compliance, and adherence to standards.
Qualifications:
- Education: Bachelor’s degree in Healthcare Administration, Nursing, Business, or related field (Master’s or compliance certification a plus).
- Experience:
- 5–7+ years in healthcare quality management, compliance, or payment integrity operations.
- Experience implementing audit/QA programs, compliance frameworks, and process controls.
- Strong knowledge of claims processing and PI functions (DRG, HBA, COB, IBR, edit engines).
- Skills:
- Strong analytical skills with the ability to identify quality trends and root causes.
- Excellent organizational and documentation skills.
- Ability to influence and collaborate across multiple functions.
- Familiarity with audit tools, data analysis software, and compliance reporting platforms.
Preferred Experience:
- Experience with CMS program audits, RAC/Medicare Advantage compliance, and commercial payer policies.
- Lean Six Sigma, CHC (Certified in Healthcare Compliance), or equivalent quality/compliance certification.
- Prior leadership of a quality/compliance team in a payer, SIU/FWA, or PI environment.
