Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.
The AVP of Program Integrity will lead the strategy, execution, and continuous improvement of pre-pay and post-pay audit concepts. This leader brings deep payer-side expertise, strong clinical and coding knowledge, and the ability to translate regulatory and payer policies into scalable and profitable audit logic.
The role partners with Audit Operations, IT, Sales, and Client Leadership to expand Sagility's end-to-end Payment Integrity value proposition, ensuring industry-leading medical cost savings, operational excellence, high quality, and strong client trust.
AVP Program Integrity - Ideation and Analytics
Operational Leadership
- Direct multi-disciplinary PI teams including Ideation SMEs, Pricing Analysts, auditors, and program integrity staff.
- Build and scale high-yield pre-pay and post-pay audit operations delivering measurable savings and ROI.
- Establish centralized workflows, SOPs, quality assurance programs, and performance dashboards.
Payment Integrity Strategy & Ideation
- Lead development of innovative audit concepts across data mining and clinical review.
- Use analytics to uncover trends, patterns, atypical billing behavior, and outlier providers.
- Translate regulatory and medical policy changes into proactive PI strategies and editable audit logic.
Pricing, Policy & Regulatory Interpretation
- Interpret complex Medicaid, Medicare, and commercial reimbursement rules.
- Partner with the pricing team to convert pricing guidelines into automated pricer logic within PI tools.
- Ensure accuracy, compliance, and scalability of contract audit methodologies.
.Fraud, Waste & Abuse (FWA) Oversight
- Provide strategic oversight of SIU/FWA functions including investigators, managers, and directors.
- Drive enterprise-wide FWA risk assessments and ensure compliance with federal/state regulations.
- Build relationships with industry bodies (BCBSA, NHCAA, law enforcement, regulatory agencies).
Client Engagement & Growth Support
- Serve as a PI subject matter expert in client discussions, sales cycles, and go-to-market strategy.
- Understand client goals, identify opportunity areas, and co-create PI roadmaps.
- Monitor KPIs for client engagement, satisfaction, and revenue growth.
Vendor Management
- Oversee PI vendor relationships including claims editing partners, overpayment recovery partners, and audit vendors.
- Ensure vendor staff effectiveness, compliance, and alignment with enterprise PI strategy.
Performance & ROI Governance
- Develop reporting metrics to track medical cost savings, team productivity, quality, and ROI.
- Drive long-term performance improvement; replicate and scale successful PI concepts.
- Achieve aggressive year-over-year gains similar to prior ROI increases demonstrated in earlier roles.
QUALIFICATIONS
Required
- 10+ years of healthcare experience in Payment Integrity, SIU/FWA, coding compliance, and audit operations.
- Exceptional Executional Skills – meet numbers/goals and objectives
- Demonstrated success building centralized PI programs (pre-pay, post-pay, policy, edits, chart review).
- Strong experience with payer environments (Medicaid, Medicare, Commercial) and audit vendors.
- Expertise in developing audit concepts, pricing logic, and regulatory interpretation.
- Proven leadership of teams of 20–30+ investigators, SMEs, analysts, and auditors.
- Certifications such as AHFI and CPC (highly preferred).
- Bachelor’s degree in Criminal Justice, Finance, Healthcare Administration, or related field
Deal & Commercial Skills
- Experience supporting sales, GTM strategy, and client expansions.
- Prior leadership in a Blue Plan or large national payer.
- Experience implementing claims editing platforms and PI technologies.
KEY LEADERSHIP COMPETENCIES
- Strategic Thinking: Ability to modernize PI programs, centralize fragmented operations, and align PI capabilities with enterprise strategy.
- Operational Excellence: Skilled in workflow optimization, quality enforcement, and scaling teams.
- Data-Driven Insight: Strong use of analytics to drive ideation, risk detection, and provider behavior insights.
- Influence & Executive Presence: Represents the organization with regulators, clients, and industry forums.
- Innovation Mindset: Comfortable introducing new audit concepts, predictive risk analytics, and automation.
- YOY increase in validated audit savings and medical cost avoidance.
- Operational efficiency gains (cycle time, accuracy, auto adjudication rates).
- Expansion of Pl ideation pipeline and audit innovation throughput.
- Client NPS improvement and successful renewal/ expansion.
- Compliance audit outcomes with zero findings.
- Effective vendor governance and pricing logic modernization.
Client-Centric Orientation: Deep understanding of payer needs and ability to architect PI solutions that drive measurable value
Work@Home USAUnited States of America
