Operational Leadership

• 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.

Payment Integrity Strategy & Ideation

• 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.

Pricing, Policy & Regulatory Interpretation

• 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.

.Fraud, Waste & Abuse (FWA) Oversight

• 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).

Client Engagement & Growth Support

• 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.

Vendor Management

• 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.

Performance & ROI Governance

• Develop reporting metrics to track medical cost savings, team productivity, quality, and ROI.
• Drive long-term performance improvement; replicate and scale successful PI concepts.
• Achieve aggressive year-over-year gains similar to prior ROI increases demonstrated in earlier roles.

QUALIFICATIONS

Required

• 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

Deal & Commercial Skills

• Experience supporting sales, GTM strategy, and client expansions.
• Prior leadership in a Blue Plan or large national payer.
• Experience implementing claims editing platforms and PI technologies.

KEY LEADERSHIP COMPETENCIES

• Strategic Thinking: Ability to modernize PI programs, centralize fragmented operations, and align PI capabilities with enterprise strategy.
• Operational Excellence: Skilled in workflow optimization, quality enforcement, and scaling teams.
• Data-Driven Insight: Strong use of analytics to drive ideation, risk detection, and provider behavior insights.
• Influence & Executive Presence: Represents the organization with regulators, clients, and industry forums.
• Innovation Mindset: Comfortable introducing new audit concepts, predictive risk analytics, and automation.

• YOY increase in validated audit savings and medical cost avoidance.
• Operational efficiency gains (cycle time, accuracy, auto adjudication rates).
• Expansion of Pl ideation pipeline and audit innovation throughput.
• Client NPS improvement and successful renewal/ expansion.
• Compliance audit outcomes with zero findings.
• Effective vendor governance and pricing logic modernization.