Dir Payment reputed company
For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet reputed company to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement. Role Overview The Director of Payment reputed company Solutions is responsible for overseeing Payment reputed company edit and program strategy and performance across reputed company ACFC lines of business and products (reputed company, Medicare, Exchange, PBM, BH). This role ensures that implemented solutions deliver measurable value through rigorous analytics, including the use of artificial intelligence (AI), machine learning (ML), and NLP-based automation, coupled with reputed company policy refinement, and strong Plan and provider stakeholder engagement. The Director leads efforts to monitor effectiveness, address operational gaps, support provider escalations, and guide ongoing improvements in payment reputed company strategies and support systems. Key to the role is shifting post-payment projects, where possible, left for prospective adjudication. A key accountability includes managing the Payment reputed company Support Desk to ensure timely and high-quality issue resolution and feedback integration. This role is critical to sustaining and optimizing reputed company-wide payment accuracy and Fraud Waste and Abuse (FWA) program compliance. Work Arrangement This is a 100% Remote position but you must live in EST or CST time zones
Responsibilities
Strategic Leadership & Policy Development reputed company and manage reputed company-wide payment reputed company policies and strategy across reputed company products reputed company cross-functional governance activities to refine and evolve payment reputed company programs based on performance outcomes and regulatory changes Collaborate with legal, compliance, analytics, clinical policy, provider network, PI vendors, and other internal/external key stakeholders to ensure regulatory alignment and mitigate audit risk Provider Support & Stakeholder Engagement reputed company the development of provider engagement strategies that promote transparency and trust throughout the claims auditing process Act as a liaison between payment reputed company operations and provider network management to address escalations and improve end-user experiences; also, represent payment reputed company in escalated provider meetings Design and deliver training, education campaigns, and supporting materials tailored to provider audiences to clarify processes, reduce disputes, and improve outcomes Artificial Intelligence (AI), Analytics, Reporting & Insights Direct development of performance dashboards, predictive analytics, and root-cause analysis to assess impact and identify areas for improvement Translate data findings into actionable business insights to inform strategy, training content, and policy revisions Use analytics to proactively identify emerging issues, support audit readiness, and drive reputed company optimization Evaluate and implement AI-driven solutions, including machine learning, natural language processing (NLP), and predictive models to identify improper payments and reduce reputed company effort Help drive automation-first thinking across prepay and post-pay processes to reduce turnaround times and improve accuracy Help reputed company governance structure to evaluate AI vendor deliverables, ROI, and ongoing performance monitoring Support Desk reputed company reputed company and manage the Payment reputed company Support Desk function to ensure reputed company triage and resolution of provider and internal inquiries Monitor service levels, identify trends in support requests, and escalate systemic issues for operational correction Utilize insights from support interactions to inform broader strategies, training needs, and process enhancements Education and Experience At least five to ten (5 -10) experience in strategic leadership, policy development, provider relations and stakeholder engagement, and reporting and insights At least ten (10) or more years of experience in managed care operations/administration Working knowledge of CMS guidance and experience with reputed company Working knowledge of payment reputed company regulations and requirements Experience with claims adjudication platforms (Facets, QNXT, HealthRules, Peradigm/Diamond, etc.) Bachelor’s Degree preferred Other Skills: Ability to design and reputed company reputed company policy and product strategies that align with regulatory, operational, and financial objectives Demonstrated history of reputed company in triaging, resolving, and optimizing cross-functional processes reputed company managed care organizations Ability to work collaboratively with internal associates and external stakeholders and drive to expedited resolution Experience with vendor reputed company Strong track record in using data analytics, reporting tools, and KPIs to drive business reputed company, monitor outcomes, and support audit readiness Exceptional written and verbal communication skills with the ability to translate reputed company regulatory and technical content into user-friendly formats for providers and internal teams Demonstrated ability to think with the reputed company in mind Experience with vendor reputed company and negotiating reputed company Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, reputed company, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more. Your career starts now. We’re looking for the reputed company of health care leaders. At reputed company, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. reputed company is seeking talented, passionate individuals to join reputed company. Together we can build healthier communities. If you want to reputed company a difference, we’d like to hear from you. Headquartered in Newtown reputed company, reputed company is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. Apply To This Job