Senior Manager, Payment Integrity Operations

Job Summary

The Senior Manager, Payment Integrity (PI) Operations, manages and leads critical components of L.A. Care’s enterprise Payment Integrity program, overseeing the design, execution, and continuous refinement of pre-payment and post-payment accuracy activities.

Duties

• Leads daily operations of pre-pay and post-pay PI activities, ensuring accuracy, timeliness, and effective case management.

• Oversees prospective review programs including clinical editing, code auditing, algorithm-driven controls, and provider contract/benefit interpretation.

• Ensures post-pay functions, including data mining, recovery validation, provider outreach, and reconciliation, are accurate, transparent, and compliant.

• Establishes standardized workflows, documentation, and quality review expectations across all PI teams.

• Strengthens the reliability of claims processing, increases automation and cost avoidance, manages complex PI workflows, and translates regulatory and contract-driven requirements into systematic, sustainable accuracy improvements.

• Oversees development, refinement, and implementation of new edits, rules, and clinical/non-clinical logic that reduce future payment errors.

• Oversees identification and validation of overpayments and underpayments from solicited/unsolicited sources, analytics, and vendor partners.

• Ensures recoveries follow compliant workflows, including provider notification, appeal support, repayment management, and financial reconciliation.

• Ensures post-pay insights translate into upstream corrective actions, edit changes, or preventive improvements.

• Manages operational execution of vendor-driven PI programs, ensuring strong Service level agreement (SLA) performance, validated results, and accurate financial reporting.

• Partners with cross-functional key stakeholders to resolve system issues and strengthen upstream accuracy.

• Serves as an advisor to internal partners on PI trends, risk areas, provider behavior insights, and recommended control changes.

• Maintains a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals.

Education & Experience

• Education: Not specified

• Experience: At least 6 years of Payment Integrity, Program Integrity, medical cost containment, Fraud Waste and Abuse (FWA), data mining, claim accuracy, or related experience. At least 5 years of experience in leading staff, Supervising and/or managing staff. Experience leading teams, projects, initiatives, and cross-functional groups. Experience in Medicaid, Medicare, and Commercial managed care lines of business. Experience in pre-pay and/or post-pay review, edit development, recovery operations, or claim logic development. Experience interpreting provider contracts, payment methodologies, and managed care benefit structures. Experience handling complex claim review, root-cause evaluation, and adhering to regulatory TAT requirements. Experience working with COB and Third-Party Liability (TPL) claims in a managed care setting. Experience with vendor-managed PI programs.

Skills

• Strong understanding of adjudication, coding, and the application of Division of Financial Responsibility (DOFR) to claims processing.

• Extensive knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies.

• Understanding of benefit interpretation, contract terms, and payment rules.

• Strong analytical, investigative, financial, and operational skills.

• Exceptional written and verbal communication skills, including executive communication and the ability to translate technical findings into actionable recommendations.

• Advanced project leadership, workflow management, and prioritization skills.

• Ability to collaborate with internal and external stakeholders at all levels.

• Proven problem-solving skills and ability to translate knowledge to the department.

• Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.

• Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.

• Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.

• Must have a deep understanding of financial principles.

• Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.

• Demonstrated ability to make informed decisions.

• Strong verbal, written communication and presentation skills.

• Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.

• Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

Preferred Skills

• Experience applying predictive analytics or algorithm-based PI solutions.

• Experience with SQL, BI tools, or data mining platforms.

Licenses/Certifications

• Licenses/Certifications: Not specified

Training

• Required Training: Not specified

Additional Information

• Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

• L.A. Care offers a wide range of benefits including:

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retailer Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)