Director, Revenue Recovery and Payor Audits

Job Description

Job Description

Description:

The Director, Revenue Recovery and Payor Audits provides strategic and operational leadership across reimbursement integrity, payment validation, revenue optimization, and payer oversight activities across the health system. This role is responsible for driving initiatives focused on financial accuracy, reimbursement integrity, operational improvement, and regulatory compliance across the revenue cycle continuum.

The Director partners with Revenue Cycle, Compliance, Finance, HIM, Managed Care, and Clinical Operations leadership to identify reimbursement trends, minimize revenue leakage, improve operational workflows, and mitigate financial and regulatory risk. This is a high-impact leadership role requiring strong expertise in healthcare reimbursement methodologies, payer operations, regulatory compliance, revenue cycle performance improvement, and cross-functional operational leadership within a complex, multi-payer healthcare environment.

Duties and Responsibilities

Revenue Recovery & Oversight

• Knows, understands, incorporates, and demonstrates the Healthrise Core Values in all interactions with team members, clients, and stakeholders.

• Design, implement, and continuously improve enterprise reimbursement integrity processes, payment validation strategies, and operational review frameworks, policies, and standard operating procedures.

• Oversee complex payer review activity, reimbursement escalations, external validation requests, and governmental and commercial payer inquiries.

• Lead proactive reimbursement review and revenue integrity initiatives focused on identifying payment variances, process improvement opportunities, and operational trends impacting financial performance.

• Develop and manage reimbursement resolution strategies including appeals coordination, payer dispute management, escalation support, and external review processes.

Team Management & Development

• Recruit, lead, and develop a team of revenue recovery analysts, reimbursement specialists, and operational review personnel; set performance goals and ensure staff education and training.

• Establish workflows, productivity standards, and quality metrics for reimbursement review, payment integrity, denial prevention, and revenue performance tracking.

• Foster a culture of continuous improvement, compliance, and professional development within the revenue integrity organization.

Compliance & Regulatory Oversight

• Ensure all reimbursement integrity and payment review activities comply with CMS regulations, OIG guidance, False Claims Act requirements, and applicable state laws.

• Monitor changes in federal and state reimbursement regulations, payer policies, and compliance requirements, reimbursement policies, and payer contracts; update internal processes accordingly.

• Partner with the Compliance and Legal teams to manage reimbursement and compliance-related risk, voluntary disclosures, and corrective action plans.

• Maintain accurate reimbursement review documentation, tracking systems, and reporting records.

Revenue Optimization & Financial Stewardship

• Drive identification and resolution of reimbursement variances and payment discrepancies impacting organizational financial performance; coordinate with Payer Relations and Contracting teams.

• Track and report on overpayment obligations, repayment timelines, and refund processes in compliance with the 60-day rule.

• Develop and maintain dashboards and KPIs to monitor audit volumes, outcomes, appeal success rates, and financial impact.

• Present regular executive-level reports on audit trends, recovery performance, and risk exposure to senior leadership.

Cross-Functional Collaboration

• Collaborate with Clinical Documentation Improvement (CDI), Case Management, Coding, and Billing teams to address root causes identified through audit findings.

• Partner with IT and Analytics to leverage technology solutions for audit tracking, data mining, and trend analysis.

• Serve as the primary subject matter expert and organizational liaison for post pay audit matters with external payers and government agencies.

• Performs other duties as assigned.

Qualifications

Required

• Bachelor’s degree in Healthcare Administration, Business, Finance, or a related field.

• Minimum 7-10 years of progressive experience in healthcare revenue cycle, with at least 5 years focused on post pay audits, claims auditing, payor audits, or revenue integrity.

• Minimum 3-5 years of leadership or management experience overseeing audit or revenue cycle teams.

• Demonstrated experience managing RAC, MAC, UPIC, OIG, or commercial payer audit responses and appeals.

• Deep knowledge of Medicare and Medicaid billing regulations and expertise in ICD-10, CPT, and HCPCS coding systems.

• Proficiency in EMR/EHR systems (Epic, Cerner, Meditech) and understanding of MS-DRG, APC, and RBRVS reimbursement methodologies.

• Advanced Excel, data analysis, and reporting skills; familiarity with PEPPER, CERT, and RAC data analytics.

• Completion of regulatory/mandatory certifications as required.

• Willingness and ability to travel to client or organizational sites as needed.

Preferred

• Master’s degree (MHA, MBA, MSN) strongly preferred.

• Experience with multi-entity or health system environments.

• Certified Professional Coder (CPC); AAPC.

• Certified Coding Specialist (CCS); AHIMA.

• Certified Revenue Cycle Professional (CRCP).

• Certified Healthcare Financial Professional (CHFP); HFMA.

• Certified in Healthcare Compliance (CHC); HCCA.

Physical Demands and Work Environment

• Primarily office-based with the option for hybrid work arrangements based on operational needs.

• Prolonged periods of sitting at a desk and working on a computer.

• Ability to communicate clearly in person, by phone, and via video conference.

• Occasional travel may be required for multi-site oversight, payer meetings, or industry conferences.

• Extended hours may be required during peak audit response periods or regulatory deadlines.