Director, Payment Integrity Strategy & Operations
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
JOB SUMMARY
The Director of Payment Integrity Strategy and Operations provides strategic leadership and oversight in the design, execution, and optimization of Payment Integrity (PI) programs focused on enhancing payment accuracy and driving member affordability. This role serves as a key liaison for all reimbursement policy and PI initiatives, helping to align cost of care goals, drive ideation and prioritization, establish governance for reimbursement policies, and coordinate performance management across the program. This leader partners closely with stakeholders in Health Care, Finance, and external payer organizations to identify, develop, and implement innovative and effective PI strategies.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Operational Oversight & Performance Management
Manages day-to-day PI operations, ensuring execution of process improvements and program redesigns.
Oversees team performance, implements internal evaluations, and coordinates with vendors and solution partners.
Guides the development of new PI models and reimbursement engagement strategies
Strategic Leadership & Program Development
Develops and drives the overall strategy for Payment Integrity (PI), aligning cost of care initiatives with enterprise goals.
Sets SMART goals, leads ideation and vetting processes, and establishes KPIs to monitor and evaluate success.
Partners with actuarial and finance teams to develop business cases and monitor financial outcomes.
Applies project management frameworks (including RACI models) to manage cross-functional initiatives.
Drives organizational change, facilitates execution of strategic roadmaps, and aligns project milestones to overall business goals.
Designs dashboards and reporting tools to track program performance and communicate insights to executive leadership.
Leads internal and external evaluations and aligns department metrics with corporate objectives and financial strategies.
Reimbursement Policy & Governance
Leads the development and management of reimbursement policies. Establishes and facilitates Reimbursement Policy Governance Committees for Commercial and Medicare lines of business.
Communicates updates, solicits feedback, and documents approvals and concerns
Enterprise & External Collaboration
Serves as a liaison and thought leader for PI across the enterprise and with external organizations and other payer organizations.
Leads cross-functional meetings and governance committees to communicate strategy, share insights, and align on cost of care efforts.
Other Duties Assigned
Reports to Position Title: VP, Operations or Sr. Director of Operations
QUALIFICATIONS:
Education/Specialized Training/Licensure: Bachelor's degree and 10 years of experience in reimbursement policy, provider reimbursement, and/or strategic or product development required.
Work Experience (Years and Area): Must have direct health plan experience required.
Previous experience directly with business case development, financial and market analysis and/or process redesign Experience with Payment Integrity products and solutions required.
Experience with strategy frameworks/roadmaps and change management preferred.
Management Experience (Years and Area): 7 years leadership experience, leading people and/or complex cross-divisional projects or programs required.
History of high performance and leadership in a matrixed organization preferred.
Job Family/Job Title Competencies
Leadership
Attention to Detail
Problem Analysis
Customer Oriented