POSITION SUMMARY
The Director of Payment Integrity, Hospital & Ancillary Performance is responsible for establishing and maintaining a structured, data-driven framework for financial oversight, vendor performance monitoring, and payment integrity across ancillary providers, delegated entities (FDRs), and hospital partners.
This role emphasizes analytics, reconciliation controls, proactive identification of financial and operational risk, and cross-functional accountability. The position represents a shift from historic relationship-based vendor management to a disciplined, performance-driven model focused on financial integrity, contract optimization, and enterprise-wide oversight as the company has evolved and grown rapidly.
This is position is fully onsite, Monday – Friday.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to:
Payment Integrity & Financial Oversight
- Develop and maintain invoice validation and reconciliation processes across all ancillary vendors, FDRs, and hospital partners
- Monitor PMPM trends, financial variances, and invoice sufficiency
- Identify and escalate discrepancies, overpayments, and financial risk indicators
- Ensure alignment between invoices, encounter data, and contractual terms
Dashboarding & Performance Monitoring
- Design and implement a comprehensive dashboard suite for vendors, FDR, and hospital performance
- Establish KPIs, SLAs, and performance metrics across all partners
- Monitor trends and proactively identify performance issues requiring intervention
- Support executive and Board-level reporting
Re-Contracting & Cost/Performance Optimization
- Establish structured re-contracting strategies across ancillary vendors, FDRs, and hospital partners
- Ensure proper cadence of re-contacting and re-negotiation activities
- Evaluate contractual performance against cost, utilization, and service benchmarks
- Identify limitations within existing agreements and recommend improvements
- Support leadership in improving financial outcomes through contract optimization
FDR & Vendor Performance Management
- Implement structured performance monitoring across delegated vendors
- Track compliance, CAPs, SLA adherence, and audit outcomes
- Drive accountability through data-driven insights
- Coordinate with Compliance and Delegation Oversight functions
Hospital Performance Oversight
- Monitor hospital financial and operational performance
- Identify contractual exposure points and performance risks
- Support leadership in evaluating utilization, cost trends, and contract effectiveness
- Align hospital oversight with broader payment integrity strategy
Joint Operating Committees (JOCs) & Governance
- Establish and maintain formal Joint Operating Committees (JOCs) across hospital and FDR/vendor relationships
- Ensure consistent cadence of meetings and structured agendas
- Drive cross-functional participation (Finance, IT, Provider Network, Compliance, Operations)
- Track action items and ensure accountability and follow-through
Cross-Functional Coordination
- Partner with Finance, Compliance, Operations, IT, and Network teams
- Ensure alignment across reporting systems and data sources
- Support enterprise-wide payment integrity initiatives
Project Management & Process Improvement
- Lead initiatives to improve financial controls, reporting capabilities, and operational processes
- Implement scalable systems to replace manual tracking methods
- Drive continuous improvement across oversight and performance frameworks
SUPERVISORY RESPONSIBILITY
People Leadership
- May supervise analysts, coordinators, or managers as the function expands
- Provides leadership, direction, and performance oversight for assigned staff
- Responsible for setting priorities, monitoring performance, and ensuring accountability
QUALIFICATIONS AND EDUCATION
Required Qualifications
- Bachelor’s degree in Finance, Economics, Business, or related field
- 8–10+ years of experience in healthcare operations, financial analysis, payment integrity, or vendor oversight
- Demonstrated experience in financial analysis, reporting, and performance monitoring
- Strong understanding of healthcare vendors and/or hospital operations
Preferred Qualifications
- MBA or advanced degree
- Experience in Medicare Advantage or Managed Care
- Experience developing dashboards and reporting frameworks (e.g., Power BI or similar tools)
- Experience with contract performance evaluation and cost optimization
Core Competencies
- Financial Acumen
- Analytical Thinking
- Strategic Planning
- Project Management
- Cross-Functional Leadership
- Problem Solving & Decision Making
- Process Improvement
- Accountability & Execution
WORKING CONDITIONS
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
- The noise level in the work environment is usually moderate.
- Works in the field
- Interacts with patients, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.
This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.
The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
PERFORMANCE MEASUREMENTS
- Duties accomplished at the end of the day/month.
- Attendance/punctuality.
- Compliance with Company regulations.
- Safety and Security.
- Quality of work.
This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.
The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.
Employee Acknowledgement:
I have read this job description and understand what is expected of me while I occupy this role.