Director, Payment Integrity

Role Overview

• Build and operationalize an internal Payment Integrity Unit, including talent strategy, workflows, and performance metrics.
• Develop, execute, and sustain a strategic roadmap for insourcing payment integrity functions in collaboration with IT and Configuration teams aligned with organizational objectives and cost of care targets.
• Establish governance and oversight structures to ensure accountability, transparency, and compliance with regulatory requirements.
• Lead vendor selection, contracting, implementation, and ongoing performance management including maintaining a minimum 4:1 return-on-investment (ROI).
• Oversee vendor-driven initiatives such as: Pre
• and post-payment data mining, Clinical reviews, Subrogation, Itemized bill reviews, Coordination of Benefits (COB).
• Partner with all units currently performing PI or COB activities to centralize these functions into a single Payment Integrity unit, ensuring a smooth and effective transition of responsibilities where appropriate.
• Lead the design, implementation, and continuous improvement of all payment integrity functions: Pre
• and Post-Payment Coordination of Benefits, Pre
• and Post-Payment Data Mining, Pre
• and Post-Payment Clinical Reviews, Subrogation and Third-Party Liability Recovery, Itemized Bill Reviews for inpatient and outpatient claims while providing strategic guidance and subject-matter expertise to vendor partners to address high-risk waste areas.
• In parallel, build and maintain an internal payment integrity team to insource key capabilities over time and reduce the organization’s vendor footprint.
• Expand and enhance the Unsolicited Refund Process, including: Trending unsolicited refunds to identify systemic issues, Collaborating with Claims and Configuration to improve adjudication logic, Mitigating future overpayments through process improvements.
• Partner with internal departments (Claims, Finance, IT, Utilization Management, Provider Network Management, Compliance) to socialize initiatives and embed payment integrity strategies into enterprise initiatives.
• Work with Provider Network Management to support provider education and training on compliant billing practices under state, federal, and commercial guidelines.
• Collaborate with IT and Configuration to implement system edits, automation, and analytics tools that support insourced capabilities.
• Direct the development of advanced analytics and executive dashboards to inform strategic decisions, forecast trends, monitor savings and recoveries, and identify emerging opportunities for financial optimization.
• Analyze data to identify new opportunities for cost avoidance and recovery.
• Present findings and strategic recommendations to executive leadership.
• Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Requirements

• Minimum of seven(7) years of progressive healthcare administration experience in payment integrity, special investigations, or healthcare anti-fraud, inclusive of a minimum of two (2) years of experience with an HMO or managed care experience.
• Proven leadership experience, mentoring, and developing a team at a leadership level
• Experience in Vendor Partner Oversight; contracting and vendor management of external payment vendors and/or audit firms
• Preferred: Medi-Cal and/or Medicare claims experience
• Bachelor's degree in Business Administration, Accounting, or Healthcare from an accredited institution required
• Preferred: Master’s degree in a related field from an accredited institution

Benefits

• Competitive salary
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance