Are you a strategic leader ready to shape the future of healthcare payment integrity? MVP Healthcare is seeking a visionary Senior Director of Payment Integrity & Cost Containment to lead enterprise-wide initiatives that ensure claims are paid accurately, ethically, and efficiently. This high-impact role safeguards financial integrity, strengthens provider trust, and drives innovation in fraud prevention and cost containment.
What's in it for you: - Growth opportunities to uplevel your career
- A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team
- Competitive compensation and comprehensive benefits focused on well-being
- An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District, one of the Best Companies to Work For in New York, and an Inclusive Workplace.
Your key responsibilities: Strategic Leadership & Program Oversight
- Develop and execute a comprehensive payment integrity strategy aligned with financial and operational goals.
- Oversee pre- and post-payment integrity programs including claims editing, audits, subrogation, readmission reviews, and coordination of benefits.
- Continuously refine strategy to address emerging trends such as value-based care, regulatory shifts, and fraud schemes.
Operational Excellence & Process Improvement
- Champion Lean and Six Sigma methodologies to streamline workflows and reduce administrative costs.
- Improve first-pass claims accuracy and reduce provider disputes through process redesign and automation .
- Lead root cause analyses and corrective action planning for systemic payment errors.
Vendor Management & Performance Monitoring
- Manage external vendors supporting audit, analytics, and fraud detection.
- Monitor vendor performance against SLAs and KPIs; negotiate contracts and ensure accountability.
- Track and report key metrics such as recovery rates, audit turnaround times, and dispute resolution outcomes.
Fraud, Waste & Abuse (FWA) Prevention
- Lead FWA detection efforts in collaboration with SIU and compliance teams.
- Leverage predictive analytics and rules engines to identify suspicious billing patterns.
- Ensure timely investigation, documentation, and resolution of FWA cases.
Clinical Coding & Documentation Accuracy
- Ensure correct coding and reimbursement aligned with ICD-10, CPT/HCPCS, DRG, and CMS guidelines.
- Serve as a subject matter expert on complex coding issues and documentation standards.
- Provide training and oversight to internal teams and vendors on coding compliance.
Regulatory & Industry Engagement
- Integrate payment integrity efforts with care quality initiatives, including avoidable readmissions and preventable complications.
- Collaborate with medical management and quality teams to align incentives and reduce unnecessary utilization.
Regulatory Compliance & Industry Engagement
- Monitor and ensure compliance with CMS, Medicaid, ACA, and state-specific regulations.
- Lead responses to regulatory audits and inquiries.
- Represent the organization in national forums including AHIP, AAPC, HPRI, NHCAA, New York State DFS, DOH, and HPA.
Innovation & Technology Strategy
- Drive adoption of AI, machine learning, and automation in audit workflows and fraud detection.
- Pilot emerging technologies and integrate them into core operations .
- Collaborate with IT and analytics teams to enhance data infrastructure and reporting capabilities.
Team Leadership & Talent Development
- Build and mentor a high-performing team with expertise in coding, analytics, and clinical auditing.
- Provide training, career development, and succession planning for critical roles.
- Foster a culture of collaboration, innovation, and continuous learning.
Cross-Functional Collaboration
- Partner with Claims Operations, Finance, Provider Relations, Compliance, IT, and Care Management to ensure payment integrity is embedded across the organization.
- Translate complex technical concepts into actionable insights for diverse stakeholders.
Thought Leadership & National Representation
- Serve as a national expert and thought leader in payment integrity and cost containment.
- Represent the organization at industry conferences such as AHIP, AAPC, and HPRI.
- Engage with regulatory and policy bodies including NHCAA, New York State DFS, DOH, and HPA.
- Influence national policy and best practices through public speaking, advisory roles, and strategic partnerships.
Qualifications you'll bring: Required
- 8-10+ years in healthcare operations, including 5+ years in leadership.
- Bachelor's or diploma in health information management or equivalent experience.
- Deep expertise in claims processing, coding, reimbursement methodologies, and fraud prevention.
- Proven success in strategic planning, vendor management, and cross-functional collaboration.
- Strong executive communication and stakeholder engagement skills.
- Curiosity to foster innovation and pave the way for growth.
- Humility to play as a team.
- Commitment to being the difference for our customers in every interaction.
Preferred
- Senior leadership experience in payment integrity or cost containment.
- Multi-line expertise (Medicaid, Medicare, Commercial).
- Certifications such as: CPC (Certified Professional Coder), CCS (Certified Coding Specialist), CFE (Certified Fraud Examiner), CHFP (Certified Healthcare Financial Professional), Lean Six Sigma, CDEO (Certified Documentation Expert Outpatient), Healthcare Anti-Fraud Associate (HCAFA), CRS (Certified Risk Specialist).
- Familiarity with platforms like Cotiviti, Optum CES, or ClaimsXten.
Leadership Traits
- Visionary : Sets bold direction for cost containment and payment integrity.
- Collaborative : Builds trust across departments, providers, and external partners.
- Decisive : Makes timely, informed decisions under pressure.
- Empowering : Develops talent and fosters accountability.
- Resilient : Navigates ambiguity and drives progress.
- Influential : Serves as a national voice in healthcare reform, shaping policies and practices through public speaking, advisory roles, and thought leadership at forums such as AHIP, AAPC, HPRI, NHCAA, New York State DFS, DOH, and HPA.
Where you'll be:
Pay Transparency MVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role. We do not request current or historical salary information from candidates. MVP's Inclusion Statement At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration. MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam-era or special disabled Veteran or other legally protected classifications.To support a safe, drug-free workplace, pre-employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team at ...@mvphealthcare.com .