Director, Payment Integrity

Director, Payment Integrity

The Director, Payment Integrity will build and lead Judi Health's payment integrity program from inception, establishing the infrastructure, processes, and team that will ensure claims are paid correctly, compliantly, and efficiently across our commercial plan population.

This is a strategic, hands-on leadership role for a subject matter expert who thrives in a build environment. In the near term, this role will personally define Judi Health's reimbursement policies and design, develop, implement, and maintain prepay claim edits as well as other payment integrity functions. Over time, this role will recruit and lead a team capable of expanding the program into DRG validation, itemized bill review, COB/TPL and broader fraud, waste, and abuse (FWA) initiatives. This role will define Judi Health's Payment Integrity roadmap and architect this function for Judi Health.

Position Responsibilities:

• Define, publish and maintain Judi Health's reimbursement policies.
• Work with clients to ascertain client-specific set of reimbursement policies.
• Design and develop Judi Health's prepay edit library from the ground up, leveraging industry-standard logic and commercial payer best practices
• Implement, test, and validate prepay edits across claim types including professional, facility, and ancillary
• Establish edit maintenance workflows to keep rules current with coding updates (CPT, ICD-10, HCPCS), payer policy changes, and regulatory requirements
• Identify appropriate sources for claim edit content (e.g. ACS, CMS, AMA) and work with product team to establish regular updates and translation of codes to those needed in rule production.
• Define the long-term payment integrity program strategy, including phased expansion into post-pay review, DRG audits, and itemized bill review
• Lead 'buy vs. build' decision-making, evaluating vendor solutions against internal development options based on cost, capability, and scalability
• Identify and address claim payment leakage across prepay and post-pay channels, with accountability for measurable medical cost savings
• Analyze claims data to surface patterns of billing errors, upcoding, unbundling, duplicate billing, and other improper payment risks
• Develop and oversee DRG validation audit processes, ensuring inpatient claims are billed at the appropriate severity and complexity
• Build and manage an itemized bill review program for high-dollar inpatient and outpatient claims
• Establish and monitor key performance indicators (KPIs) for edit performance, savings yield, false positive rates, and provider dispute outcomes
• Ensure all payment integrity activities comply with applicable commercial insurance regulations
• Monitor changes in commercial payer policy, coding guidelines, and regulatory requirements and translate them into timely program adjustments
• Partner with Compliance and Legal to ensure FWA activities meet regulatory standards and documentation requirements
• Maintain audit-ready documentation for all edit logic, policy rationale, and program decisions
• Serve as the organizational subject matter expert on payment integrity, educating internal stakeholders on program rationale, edit logic, and savings impact
• Collaborate with Product, Claims Operations, Medical Management, Provider Relations, Finance, and Technology to integrate payment integrity into end-to-end claim workflows
• Partner with analytics and technology teams to define data requirements, reporting infrastructure, and tooling that support program scale
• Represent payment integrity in provider dispute resolution, escalations, and cross-functional issue management
• Develop and execute a staffing plan to grow the payment integrity team as program scope expands
• Recruit, hire, and develop payment integrity professionals including clinical coders, auditors, and analysts
• Foster a collaborative, high-performance team culture grounded in accuracy, accountability, and continuous improvement
• Serve as a mentor and technical resource for team members, building internal coding and audit expertise

Required Qualifications:

• Bachelor's degree and a minimum of 10 years of progressive experience in payment integrity, healthcare claims, or a related field
• Deep subject matter expertise in commercial health plan payment integrity, including prepay edit development and claims adjudication
• Demonstrated experience developing or managing prepay edit programs, including rules logic design, implementation, and maintenance
• Strong working knowledge of commercial billing guidelines, CPT, ICD-10-CM/PCS, HCPCS, revenue codes, and claim editing logic (e.g., NCCI, MUE, RVU-based edits)
• Proven track record of generating medical cost savings through payment integrity initiatives
• Experience operating in a player-coach capacity, comfortable doing hands-on technical work while setting strategic direction
• Exceptional analytical, communication, and leadership skills
• Professional coding credential (CPC, CCS, or equivalent)

Preferred Qualifications:

• Experience with DRG validation audits and/or itemized bill review programs
• Experience building or scaling a payment integrity function at a health plan or payment integrity vendor
• Knowledge of SQL, data querying tools, or business intelligence platforms
• Experience evaluating and implementing third-party payment integrity vendors or software solutions
• People management or department leadership experience
• Familiarity with FWA detection methodologies and SIU referral processes