Healthcare Integrity & Assurance, Principal

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About the Role

Lead and strengthen the Healthcare Integrity & Assurance (HIA) function's reporting, audit consistency, and integrity oversight across the healthcare claims value chain. Oversee the consolidation of insights across QA and FWA activities, ensuring audit frameworks, methodologies, and outputs are consistently applied and translated into clear management visibility of claims integrity risks.

Roles and Responsibilities

1. Integrity Reporting & Insights

Lead the preparation and consolidation of reporting across the HIA function including QA audit performance, MCAT investigation statistics, audit activity volumes, claims integrity trends, and financial impact reporting. Support preparation of reporting for management updates, EXCO reporting, and ad-hoc leadership briefings while ensuring reporting provides clear and structured insights on emerging integrity risks.

2. Audit Framework & Methodology Support

Lead the development, maintenance, and consistent application of audit review methodologies across QA and MCAT activities. Review audit outputs prior to escalation to ensure clarity, analytical rigor, and consistency in interpretation of claims findings while maintaining audit SOPs and review procedures.

3. Audit Findings Tracking & Follow-Up

Track key findings and recommendations arising from QA and MCAT reviews and monitor progress of follow-up actions with relevant stakeholders. Consolidate recurring themes or patterns identified through audit activities to support management discussions on claims integrity risks.

4. Cross-Team Coordination

Drive alignment and coordination across QA and MCAT audit teams while facilitating discussions with relevant stakeholders including Claims, Risk, and other internal functions where appropriate. Support preparation of materials for discussions relating to claims integrity trends and audit insights.

5. Strategic & Leadership Support

Support the AD of Healthcare Integrity & Assurance in preparing executive briefings, presentations, and analysis for senior leadership engagement. Translate audit data and review insights into concise management narratives that support leadership understanding of integrity risks.

Minimum Job Requirements:

• Bachelor's degree in Finance, Healthcare, Business, or related field
• 6-10 years of experience in insurance claims, audit, compliance, or fraud investigation environments
• Experience in claims audit, fraud detection, or integrity oversight preferred
• Strong analytical and reporting capabilities with advanced Excel proficiency
• Familiarity with Power BI or other data visualization tools is an advantage
• Strong organizational and stakeholder management skills