AVP Program Integrity - Ideation and Analytics
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 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.
Job title:
Job Description:
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.
- SUCCESS MEASURES
- 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
Location:
Work@Home USAUnited States of America