AVP Payment Integrity Operations

Sagility is a tech-enabled BPM services provider, a thought partner providing a broad spectrum of transformational services, to enable our clients provide efficient and hi-quality care across the healthcare system.

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. We optimize the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics.

Leading industry analyst firms have consistently cited our service excellence, breadth of offerings, and ability to execute. The most recent being recognized as a leader for Healthcare Payer Operations in 2022 as a part The Healthcare Payer Operations PEAK Matrix Assessment report by Everest Group.

We have 35,000+ employees in 15 cities across 5 countries – India, Philippines, USA, Jamaica, and Colombia.

About SPIS ( Sagility Payment Integrity Services)

Sagility’s approach to Payment Integrity (PI) is a collaboration between our data mining, coding and clinical teams that provides predictable operational excellence through analytics-led, technology-driven solutions. Backed by our proprietary Intelligent Content Processing (ICP) software, we deliver high quality, broad automation driven by more accurate findings. Through our HITRUST certified platform, Contract Central, we provide Data Mining, Clinical Audit and Claims Repricing solutions that enhance claims payment accuracy and ensure significant savings in both pre and post-pay.

Sagility is currently hiring for a talented Associate Vice President (AVP) of Payment Integrity Operations. This role will oversee and manage the operational activities related to payment accuracy,  and cost containment across various payment systems for a portfolio of Data Mining clients. This leader will be responsible for ensuring the efficient, effective, and compliant operation of payment integrity functions within the organization in collaboration with other AVP’s who manage another set of clients.  The incumbent will collaborate with cross-functional teams to drive operational excellence, increased automation, implement strategic initiatives, and ensure achievement of company and client specific financial and quality goals, adherence to policies and regulations.

Job Summary:

The successful candidate is accountable directly and indirectly through a matrix team. You will be partnering with key value streams and business units within Sagility Payment Integrity Organization. This role is essential for supporting the mission of affordable health system for all and drive financial savings. Working within the Business Performance Unit, you will have the opportunity to work collaboratively within a high-performance team, responsible for driving successful Transformation Program. This position requires a deep understanding of healthcare billing, reimbursement systems, regulatory compliance, and effective leadership skills.

Key Area of Responsibilities:

Operational Management: Lead & oversee daily operations related to payment integrity, ensuring all functions are performed in compliance with relevant regulations, standards, and corporate policies. Monitor and ensure the effective use of payment integrity technologies, including data analytics tools and automation solutions, to streamline operations. Ensure timely and accurate resolution of payment discrepancies, disputes, and escalations, coordinating with internal teams and external stakeholders as needed. Collaborate with other AVP’s to prioritize IT work, new audit implementations, new technology updates.

Payment Integrity Strategy: Define and execute strategies to enhance overpayments, accuracy of results, reduce overhead costs per recovery dollar, and mitigate financial risk in payment processes. Drive initiatives to detect, investigate, and submit overpayments to clients Develop and implement process improvements to increase efficiency, accuracy, and compliance in payment integrity operations.

Data Analysis & Reporting: Use data analytics to identify trends, risks, and areas for improvement in payment processing and integrity. Prepare and present regular reports and dashboards to senior leadership, highlighting performance metrics, issues, and opportunities for operational enhancement. Ensure the development and maintenance of accurate documentation and reporting processes.

Compliance & Regulatory Adherence:

• Ensure that all payment integrity activities comply with applicable healthcare regulations (such as HIPAA, Medicare/Medicaid guidelines, and payer contracts).

• Monitor and audit payment processes to ensure adherence to internal policies and external regulatory standards.

• Support internal and external audits related to payment integrity.

• Stay informed about industry trends, regulations, and best practices to maintain compliance and enhance operational efficiency.

Budget and Resource Management: Develop and manage the budget for the Payment Integrity department, ensuring efficient allocation of resources. Identify opportunities to optimize operational costs while maintaining high service quality and compliance standards. Work with the technology team to automate wherever possible to reduce audit turn around times, improve quality and drive staff efficiencies

Technology Utilization & Tools:

• Leverage payment integrity systems and software tools to track and monitor claims and payment discrepancies.

• Collaborate with IT to ensure proper system functionality and data integration across platforms.

• Utilize advanced Excel functions, SQL queries, or business intelligence tools

Key Attributes:

• Analytical mindset with a problem-solving approach.

• Detail-oriented and focused on accuracy and compliance.

• Strong decision-making and strategic thinking abilities.

• Process oriented thinking with a mindset of efficiency, accuracy and time savings

• Ability to manage multiple priorities and thrive in a fast-paced, dynamic environment.

• Proactive and results-driven with a passion for improving operational processes.

Education & Experience:

• Bachelor’s degree in healthcare administration, Business, or a related field. Master's degree preferred.

• Understanding of claims processing and the lifecycle of a claim.

• Minimum of 10-12 years of experience in healthcare, with focus on leading Operations within the Payment Integrity Vertical on Health Plan & Vendor.

• Knowledge of healthcare economics

• Experience in directly interfacing with and managing clients.

• Proficiency with payment processing systems, fraud detection tools, and data analytics platforms.

• Advanced Excel skills and experience with reporting and business intelligence tools.

Skills & Competencies:

• Strong leadership and team management skills, with the ability to inspire and develop a diverse team.

• Deep knowledge of payment integrity concepts, fraud detection techniques, and cost containment strategies.

• Expertise in using data analytics tools and automation technologies to drive operational improvements.

• Strong understanding of compliance regulations and risk management practices.

• Excellent communication and stakeholder management skills, with the ability to interact effectively at all levels of the organization.

• Ability to manage complex projects and initiatives, delivering results within deadlines and budget.

Preferred Skills:

Large operational experience and exposure in Payment Integrity related business operations with a combination of Pre & Post Pay environment. Someone who has layered understanding of Payment Integrity Technology/ Platform based solutions.

Salary Range starting at $200,000.00 and up dependent on experience

Sagility Offers Competitive Benefits Including:

• Medical

• Dental

• Vision

• Life Insurance

• Short-Term and Long-Term Disability

• Flexible Spending Account

• Life Assistance Program

• 401K with employer contribution

• PTO and Sick Time

• Tuition Reimbursement

Join our team, we look forward to talking with you!

An Equal Opportunity Employer/Vet/Disability