The Director of Health Claims Audit & Recovery reports to the VP Finance and is responsible for leading the strategy, operating model, and performance of the health claims audit and recovery function. This role provides enterprise-level leadership in identifying, validating, escalating, and recovering health plan payment discrepancies. The Director establishes departmental vision, governance, measurable goals, and scalable processes that support financial performance, payer accountability and operational excellence.
ESSENTIAL FUNCTIONS:
Develop, lead, and continuously advance a comprehensive claims payment audit and recovery strategy across all contracted Medicare Advantage health plans. Own departmental recovery targets, financial impact reporting, performance metrics, and executive-level updates related to claims audit and recovery performance. Establish the operating model, governance structure, workflows, concept builds, and accountability mechanisms needed to identify payment variances, and contractual inconsistencies. Direct the preparation, prioritization, submission, escalation, and resolution of payment reconsiderations, disputes, appeals, and recovery requests with health plans. Ensure timely follow-up, adjudication and collection of recoverable amounts. Serve as the senior business owner for health plan payment integrity and payer recovery initiatives. Monitor payer compliance with contract terms, fee schedules, reimbursement policies, value-based arrangement requirements, and plan-specific financial obligations. Oversee plan-specific cost reallocations and financial adjustments, in accordance with contractual and health plan policies. Partner with Finance, Accounting, Network, Contracting, Medical Management, Operations, and executive leadership to resolve systemic health plan over-billing and drive corrective action. Design scalable workflows, reporting tools, audit methodologies, and analytical capabilities to support a growing physician organization. Implement analytics-driven approaches to identify recovery opportunities and payer trends. Establish departmental KPIs, recovery targets, productivity benchmarks, quality standards, and ongoing performance reporting. Continuously assess opportunities for automation, technology enhancements, staffing optimization, and process improvements that increase recovery effectiveness and operational scalability. Consistently exhibits behavior and communication skills that demonstrate commitment to superior customer service, including quality and care and concern with all internal and external customers. Represents the Company in a professional manner, following all Company policies and procedures. Partner with the VP Finance to define departmental strategy, annual priorities, measurable goals, budget considerations, and long-term functional direction. Lead, develop, and manage team members responsible for claims audit, recovery, reporting, payer follow-up, and related financial analysis activities. Establish team structure, role expectations, workload priorities, performance standards, development plans, and accountability measures. Build and maintain senior-level relationships with Network & Contracting, health plan partners, Finance, Accounting, Medical Management, Operations, and other internal stakeholders to support claims recovery. Establish ongoing communication and escalation channels with health plan partners to resolve payment disputes, address recurring issues, and support claims audit effectiveness. Partner with Medical Management to evaluate high-cost cases, identify medical cost trends, and obtain supporting information necessary for recovery opportunities. Provide oversight, quality assurance, and strategic direction for claims audit findings, recovery submissions, dispute strategies, and payer follow-up activities. Oversee development of routine and ad hoc reporting capabilities that inform financial planning, executive decision-making, payer strategy, and operational improvement. Assess team performance and talent needs on an ongoing basis; provide coaching, feedback, succession planning, and professional development support. Perform additional duties as assigned. Must have consistent, punctual, and reliable attendance. Ability to travel may be required.
EDUCATION:
Bachelor’s Degree in a health-related field preferred or equivalent experience considered.
EXPERIENCE:
Minimum of 7-10 years of progressive experience in healthcare finance, claims audit, payment integrity, payer contract analysis or related financial operations. Minimum of 3-5 years of leadership experience managing teams, projects, or functions with measurable financial, operational, or performance accountability preferred. Experience leading payer recovery initiatives, financial performance reporting, claims dispute resolution, and cross-functional process improvement strongly preferred. Experience with ICD-10 codes, CPT codes, provider contracts, fee schedules, reimbursement methodologies, and financial analysis required.
