AVP Program Integrity - Ideation and Analytics
Work@Home USA, United States
USD 167K-250K (estimate) Executive-level Full Time
Tasks
- Analyze billing trends patterns and outliers
- Build centralized workflows and SOPs
- Conduct enterprise FWA risk assessments
- Convert pricing guidelines into automated pricer logic
- Develop audit concepts using data mining and clinical review
- Direct audit operations and continuous improvement
- Drive compliance with federal and state regulations
- Ensure accuracy compliance and scalability of audit methodologies
- Govern medical cost savings ROI and productivity metrics
- Implement quality assurance and performance dashboards
- Interpret Medicaid Medicare and commercial reimbursement rules
- Lead prepay and postpay audit strategy
- Manage PI vendor relationships and alignment
- Monitor client KPIs and satisfaction
- Oversee SIU and FWA investigations
- Provide client PI subject matter expertise
- Replicate and scale successful audit concepts
- Support sales GTM and client growth with PI roadmaps
- Translate regulatory and medical policy into audit logic
Perks/Benefits
- N/A
Skills/Tech-stack
Analytics | Audit operations | Automated Pricer Logic | Claims Editing | Clinical review | Data Mining | Fraud Waste and Abuse | Healthcare | Medicaid | Medical coding | Medicare | Outlier Detection | Payment integrity | Predictive Analytics | Pricing logic | Provider Outlier Detection | Quality Assurance | Regulatory Compliance | Risk Assessment | SIU | SOP Development | Workflow Optimization
Education
Bachelor of Arts | Bachelor of Engineering | Bachelor of Science
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