Director, Payment Integrity and Clinical Coding

Coding Integrity And Provider Reimbursement Manager

Provide enterprise-wide strategic leadership for the Coding Integrity and Provider Reimbursement teams within the Payment Integrity organization. Oversee departmental operations, policies, and procedures to ensure alignment with health plan standards and compliance with federal and state regulatory requirements. Serve as the organization's lead coding resource, advising cross-functional leaders and driving performance across internal and external programs.

Principal Accountabilities :

• Lead coding strategy and execution to achieve gross and incremental savings targets.
• Lead the development and enterprise-wide management of clinical coding guidelines, including the creation, maintenance, and alignment of policies with industry standards and regulatory requirements. Ensure a structured and compliant approach to coding integrity across all lines of business.
• Drive enterprise-wide operational efficiency and cost-effectiveness by leading the full lifecycle of strategic policy and coding initiativesfrom development and approval through implementation and communication. Evaluate and forecast the financial impact of coding and policy changes to deliver measurable medical cost savings.
• Serve as the primary coding advisor across the enterprise, ensuring consistency and compliance.
• Lead implementation and expansion of coding-related programs, including cost-benefit analysis.
• Identify and implement improvements in systems, procedures, and workflows.
• Monitor provider abrasion and drive reductions in appeal rates and recovery adjustments.
• Deliver standardized operational processes across vendors and internal teams.
• Provide mentorship and guidance to team members, fostering a culture of collaboration, innovation, and continuous learning.
• Ideate and identify new opportunities for program growth and optimization.
• Ensure adherence to applicable federal, state, and local regulations.
• Perform other related tasks / projects as directed, requested, or required.

Qualifications :