Program Integrity Director Jobs in Covington, KY

Location: Norfolk VA, Mason OH, Indianapolis IN, Louisville KY, Atlanta GA, Miami FL, Grand Prairie TX, Overland Park KS

Hours: Standard Working hours

Travel: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

Position Overview:

The Manager of Hospital Bill Audit & Itemized Bill Review leads the strategy, execution, and continuous improvement of hospital claim audits and itemized bill review functions within the Program Integrity organization. This role manages a team responsible for identifying billing errors, enforcing payment policy and contractual requirements, reducing inappropriate spend, and supporting pre- and post-payment controls through clinically and financially sound review of itemized bills (UB-04 claim forms and supporting documentation such as itemized statements and medical records, as applicable).

How You Will Make an Impact:

• Lead daily operations for hospital bill audits and itemized bill reviews, ensuring accuracy, productivity, and compliance with internal policies and regulatory standards.

• Manage, coach, and develop a team of auditors/reviewers (and potentially vendor resources), including hiring, onboarding, training, performance management, and career development.

• Establish and maintain standard operating procedures (SOPs), quality controls, and escalation pathways for complex audits and high-risk billing patterns.

• Oversee workflow intake, triage, prioritization, and turnaround time commitments for audits and bill reviews (e.g., IP, OP, ER, observation, ambulatory surgery, facility ancillary, high-dollar claims).

• Oversee itemized bill review for: revenue codes, HCPCS/CPT mapping, units/quantity validation, charge/cost reasonableness, packaging/bundling rules, NCCI edits (as applicable to setting), and duplicate or unbundled charges.

• Ensure appropriate application of: payer payment policies, CMS guidelines (where applicable), state/federal regulations, and provider contract terms (including reimbursement methodologies and carve-outs).

• Direct investigation and documentation of suspected waste, abuse, or fraud indicators and coordinate referrals to SIU/Compliance/Legal per policy.

• Support both pre-payment and post-payment audit strategies, including clinical documentation requests when required to substantiate billed services.

• Partner with analytics to identify outliers, emerging billing risks, and provider/claim targets using utilization trends, charge patterns, and audit findings.

• Translate audit results into actionable initiatives (edit development, provider education, contract language recommendations, and process improvements).

• Monitor recoveries, avoidance, overturn rates, and appeal outcomes to refine audit logic and improve defensibility.

• Own quality assurance (QA) program for audit determinations, ensuring consistent rationale, complete workpapers, and strong evidence trails.

• Oversee preparation of audit summaries, demand letters support, and appeal/negotiation packages; collaborate with Claims, Provider Relations, and Appeals teams as needed.

• Provide clear, professional communication to internal stakeholders and, when appropriate, support provider education on common billing issues.

• Ensure audits and bill reviews are performed in alignment with regulatory requirements, accreditation standards (as applicable), privacy/security rules (HIPAA), and record retention guidelines.

• Maintain audit-ready documentation practices and support internal/external audits of Program Integrity activities.

• Manage vendor oversight if external audit firms are used: scope, performance metrics, validation, and invoicing.

Required Qualifications:

• Requires a BA/BS and minimum of 5 years experience in project/program management, process reengineering, organizational design, and/or implementation; or any combination of education and experience, which would provide an equivalent background.

Preferred Qualifications:

• Bachelor's degree in nursing, or related field preferred

• Certifications: CHC, CPC, RHIA/RHIT (any relevant).

• Experience with payment integrity platforms, claims editing logic, or audit workflow tools preferred

• Experience supporting appeal defense and provider dispute resolution preferred

• Familiarity with federal and state program integrity frameworks (Medicare/Medicaid managed care environments) preferred

• Experience in hospital billing, facility claims auditing, payment integrity, or revenue integrity, including itemized bill review preferred

• People management or team lead experience (direct or matrix) preferred

• Working knowledge of hospital billing and reimbursement concepts across inpatient/outpatient settings preferred

• Experience interpreting and applying payment policy, audit standards, and provider contract terms preferred

• Strong documentation, analytical, and decision-making skills; ability to produce defensible audit findings preferred

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.