Director, Payment Integrity

Job Summary

The Director, Payment Integrity defines the payment integrity operating model. As owner, is accountable for prevention, governance, analytics, risk reduction and sustained accuracy across all prepay and post pay activity. This position is responsible for designing, leading, and continuously improving the end-to-end Payment Integrity program.

Duties

Strengthens accuracy, prevents financial leakage, and ensures upstream and downstream controls operate as a cohesive system. Refines and enhances disciplined processes, improves the sustainability of controls, and leverages data to identify and mitigate risks before they impact members, providers, or financial performance. Through cross-functional collaboration, structured execution, and proactive problem-solving, enhances the organization’s ability to manage medical spend responsibly and ensure accurate, compliant payment outcomes. Develops and executes the Payment Integrity strategy, ensuring alignment with enterprise financial, operational, and regulatory priorities. Leads a comprehensive operating model that integrates pre-pay, post-pay, clinical editing, cost-avoidance, data mining, recovery operations, COB, and TPL functions. Designs and maintains governance frameworks, policies, workflows, and quality standards that strengthen preventive controls and reduce rework. Ensures consistent application of rules, benefit interpretation, pricing methodologies, and contract terms across all Payment Integrity activities. Oversees the development and implementation of pre-payment controls including clinical editing, code auditing, configuration recommendations, automated and algorithm-based edits, and pre-pay clinical and non-clinical reviews. Partners with cross-functional teams to implement upstream changes that prevent recurring payment errors and reduce operational burden. Leads initiatives that increase automation, improve first-pass accuracy, and reduce the volume of post-pay recoveries. Oversees identification, validation, and recovery of overpayments across solicited and unsolicited sources, ensuring accuracy, transparency, and regulatory compliance. Leads recovery operations, including provider outreach, appeals support, repayment management, and reconciliation of recovery outcomes. Ensures post-pay findings feed into proactive improvements and preventive interventions, reducing future inappropriate payments. Directs internal data mining and analytical review functions to identify billing anomalies, emerging risk patterns, and cost avoidance opportunities. Partners with Analytics leaders to develop predictive models, dashboards, and trending tools that support smarter interventions and program scalability. Translates analytical insights into operational or system changes that reduce leakage and strengthen the accuracy of initial payment decisions. Oversees COB and TPL programs to ensure correct payer order, maximize cost avoidance, and support regulatory reporting requirements. Ensures timely, accurate, and complete responses to inquiries from DHCS or other regulatory bodies. Strengthens processes to reduce inappropriate payments that result from eligibility, coordination, or primary payer errors. Manages relationships with Payment Integrity vendors, ensuring contract compliance, performance against SLAs, timely implementation of new programs, and accurate financial reconciliation. Assesses vendor performance and identifies opportunities to optimize or expand program impact. Ensures vendor partners follow appropriate standards, quality controls, and documentation expectations. Ensures Payment Integrity processes meet all regulatory and contractual requirements across Medicaid, Medicare, Commercial, and Exchange lines of business. Leads or supports responses to audits, inquiries, corrective action plans, and regulatory reviews related to payment accuracy. Partners with QA to validate accuracy and consistency of Payment Integrity findings, recoveries, and interventions. Collaborates with Claims Administration, Configuration, Provider Network Management, EDI, Compliance, and Finance to address systemic issues and improve end-to-end payment outcomes. Advises leadership and internal partners on payment accuracy trends, root-cause drivers, provider impact, and mitigation strategies. Builds strong relationships with provider partners and communicates clearly on payment rules, system behaviors, and corrective actions. Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Develops, and manages budgets, utilizing resources effectively. Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals. Identifies and actualizes enhancements to support company vision. Develops and maintains relationships with key stakeholders. Leads discussions on policy operationalization and oversees key policy perspective sharing. Oversees succession planning to build technical expertise and operational consistency. Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.

Education & Experience

Education Required: Bachelor's degree in healthcare administration, finance, or a related field. Experience Required: At least 7 years of deep experience in Payment Integrity, Fraud/Waste/Abuse prevention, Claims Accuracy, Medical Cost Containment, and/or other Program Integrity functions. At least 5 years of experience leading, supervising and/or managing staff. Demonstrated experience in pre-pay and/or post-pay program oversight, cost-avoidance strategies, recovery operations, clinical editing, or data mining. Experience working with and interpreting provider contracts, benefit structures, pricing methodologies, and Medicaid/Medicare regulatory requirements. Education Preferred: Master's degree in healthcare administration, finance, or a related field. Experience Preferred: Experience developing and overseeing COB/TPL programs. Experience engaging with regulators, responding to audits, and overseeing and managing vendor partners. Experience implementing predictive analytics or algorithm-based Payment Integrity solutions.