Senior Payment Integrity Program Development Specialist

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About the role

Reporting to the Manager of Payment Integrity Program Development, the Senior Payment Integrity Program Development Specialist serves as a subject matter expert driving the research, analysis, and development of Payment Integrity initiatives that strengthen payment accuracy, reduce overpayments, and ensure regulatory and contractual compliance. This role evaluates medical cost trends, claims patterns, and industry developments to create and manage a robust backlog of audit concepts and vendor-based solutions. This position determines concept feasibility and financial impact, refines and documents logic, and partners with Clinical, Policy, and the Special Investigations Unit (SIU) to transform findings into actionable outcomes. This Senior Payment Integrity Program Development Specialist also assesses existing pre- and post-payment audit programs to enhance fraud, waste, and abuse (FWA) detection, while guiding cost avoidance improvements across Payment Integrity operations.

The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Responsibilities

• Drive research, analysis, and development of Payment Integrity initiatives to strengthen payment accuracy and reduce overpayments
• Evaluate medical cost trends, claims patterns, and industry developments to create and manage a backlog of audit concepts and vendor-based solutions
• Determine concept feasibility and financial impact, refine and document logic
• Partner with Clinical, Policy, and the Special Investigations Unit (SIU) to transform findings into actionable outcomes
• Assess existing pre- and post-payment audit programs to enhance fraud, waste, and abuse (FWA) detection
• Guide cost avoidance improvements across Payment Integrity operations
• Develop query logic from contracts, provider manuals, and billing and coding sources
• Identify and remediate errors in configuration through false positive identification and root cause analysis
• Analyze complex data sets for claims irregularities using tools like SQL or Excel
• Move from data insights to create and implement logic for concept development
• Manage competing priorities

Requirements

• Minimum of five (5) years of relevant experience required
• Experience creating concept logic, tracking performance, and working with external vendors required
• Experience with SQL or data mining
• Experience in complex claims analytics and trend evaluation
• Bachelor’s degree in business, health administration, or a related field from an accredited institution required
• In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required (in addition to the five years listed above)
• Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred

Qualifications

Strong knowledge and deep understanding of:

• The claims lifecycle, including coding (ICD-10, CPT, DRG) and reimbursement policies (NCCI, correct coding, modifiers, medical necessity, frequency limits, RBRVS, etc.)
• Managed Medi-Cal policies, DHCS updates, CMS guidelines
• Provider billing practices and common coding/bundling issues
• Payment methodologies and share of cost (Medi-Cal Rates, APR-DRG, Per diem, contractual percent of charge)
• Query logic development from contracts, provider manuals, and billing and coding sources
• False positive identification and root cause analysis of query logic to identify and remediate errors in configuration
• Claims adjudication platforms and data file layouts
• SQL and Microsoft Excel

Proven ability to:

• Analyze complex data sets for claims irregularities using tools like SQL or Excel
• Move from data insights to create and implement logic for concept development
• Manage competing priorities
• Communicate and present effectively

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

Pay

$80,059.20 USD Annually - $106,059.20 USD Annually