Date: 1 May 2025
Location: Remote, Remote, US
Company: firstsourc
Director of Adjudication and Payment Integrity
Business area

JOB SUMMARY

We are seeking an experienced Director of Adjudication and Payment Integrity to lead and provide strategic oversight of the claims adjudication function, as well as fraud, waste, and abuse (FWA) prevention, claims auditing, and cost-containment strategies in healthcare payer operations. This role will drive adjudication and payment integrity initiatives, ensuring service level agreements (SLAs) are met across all operational units, and accurate claim payments, regulatory compliance, and financial recovery optimization. Leads continuous improvement initiatives and collaborates with senior stakeholders. The ideal candidate will have strong expertise in healthcare claims processing, provider billing practices, medical policy, and data analytics to enhance payment accuracy and reduce improper payments.

EDUCATION & EXPERIENCE:

• Bachelor’s degree in healthcare administration, Business, Finance, or a related field (Master’s preferred).
• 8+ years of experience in healthcare payment integrity, claims auditing, or fraud detection.
• 3+ years in a leadership role overseeing payment integrity programs or healthcare cost-containment strategies.

SKILLS & COMPETENCIES:

• Strong knowledge of healthcare claims processing, provider reimbursement models, and payment methodologies (fee-for-service, capitation, value-based payments, etc.).
• Experience with CMS regulations, state Medicaid rules, and commercial payer compliance.
• Proficiency in healthcare fraud analytics, data mining, and predictive modeling.
• Knowledge of coding audits (ICD-10, CPT, DRG, HCPCS), medical policies, and utilization management.
• Strong stakeholder management, problem-solving, and communication skills.

PREFERRED QUALIFICATIONS:

• Certifications such as Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), or AAPC/AHIMA credentials.
• Experience with payment integrity platforms, claims analytics tools (e.g., Cotiviti, Optum, Change Healthcare, etc.), and AI-driven fraud detection.
• PMP, Six Sigma, or Agile certification.

ESSENTIAL DUTIES

• Enterprise-wide oversight and management of claims and benefit configuration activities for all BPaaS Clients
• Build successful relationships with other operational and partners by developing a clear understanding of needs, being a trusted SME on configuration feasibility, and ensuring cost-effective and accurate delivery of configuration services to meet the project needs.
• Partner with Data, Product & Engineering, and Insurance Ops to assess benefit configuration feasibility and construct scalable solutions.
• Ensure consistency and standardization in configuration processes
• Lead and mentor a team to load and configure business requirements into Core Admin Platform (E.g. HealthRules Payer) with accurate delivery.
• Identify opportunities to enhance operational workflows, automation, and process efficiencies.