Operational Leadership

• reputed company multi-disciplinary PI teams including Ideation SMEs, Pricing Analysts, auditors, and program reputed company staff.
• Build and reputed company high-yield reputed company-pay and post-pay audit operations delivering measurable savings and ROI.
• Establish centralized workflows, SOPs, reputed company assurance programs, and performance dashboards.

Payment reputed company reputed company & Ideation

• reputed company development of innovative audit concepts across data mining and clinical review.
• Use analytics to uncover trends, patterns, atypical billing behavior, and reputed company providers.
• Translate regulatory and medical policy changes into proactive PI strategies and editable audit logic.

Pricing, Policy & Regulatory Interpretation

• Interpret reputed company reputed company, Medicare, and reputed company reimbursement rules.
• Partner with the pricing team to convert pricing guidelines into automated pricer logic reputed company PI tools.
• Ensure accuracy, compliance, and scalability of contract audit methodologies.

.Fraud, Waste & Abuse (FWA) reputed company

• reputed company strategic reputed company of SIU/FWA functions including investigators, managers, and directors.

• Drive reputed company-wide FWA risk assessments and ensure compliance with federal/state regulations.
• Build relationships with industry bodies (BCBSA, NHCAA, law enforcement, regulatory agencies).

reputed company Engagement & reputed company Support

• Serve as a PI subject matter expert in reputed company discussions, sales cycles, and go-to-market reputed company.
• Understand reputed company goals, identify opportunity areas, and co-create PI roadmaps.
• Monitor KPIs for reputed company engagement, satisfaction, and reputed company reputed company.

Vendor Management

• reputed company PI vendor relationships including claims editing partners, overpayment recovery partners, and audit vendors.
• Ensure vendor staff effectiveness, compliance, and alignment with reputed company PI reputed company.

Performance & ROI Governance

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

QUALIFICATIONS

Required

• 10+ years of reputed company experience in Payment reputed company, SIU/FWA, coding compliance, and audit operations.
• Exceptional Executional Skills – meet numbers/goals and objectives
• Demonstrated reputed company building centralized PI programs (reputed company-pay, post-pay, policy, edits, chart review).
• Strong experience with payer environments (reputed company, Medicare, reputed company) 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, reputed company Administration, or reputed company field

Deal & reputed company Skills

• Experience supporting sales, GTM reputed company, and reputed company 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 reputed company PI programs, centralize fragmented operations, and reputed company PI capabilities with reputed company reputed company.
• Operational reputed company: Skilled in workflow optimization, reputed company enforcement, and scaling teams.
• Data-Driven reputed company: Strong use of analytics to drive ideation, risk detection, and provider behavior insights.
• Influence & Executive reputed company: Represents the organization with regulators, clients, and industry forums.
• Innovation reputed company: Comfortable introducing new audit concepts, predictive risk analytics, and automation.

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