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. This position ensures the accuracy of provider payments, minimized inappropriate spend, and strengthens preventive and detective controls across all lines of business. The Director oversees clinical editing, data mining, cost-avoidance strategies, recovery operations, coordination of benefits (COB), third-party liability (TPL), and analytical review of billing and payment patterns.

The Director sustains a Payment Integrity operating model that prevents incorrect payments before they occur, improves the reliability of claims processing through strong upstream controls, identifies systemic issues contributing to payment errors, and drives operational, configuration, or provider-facing changes that improve accuracy over time. This leader partners closely with cross-functional teams and external vendors to ensure sustained, measurable impact on medical cost reduction, accuracy, audit readiness, and provider experience.

The Director leads a multi-functional team that includes internal data mining, clinical review, overpayment recovery, prospective pre-payment programs, and vendor management. The Director is responsible for building analytic and operational rigor, embedding standardized processes, and fostering a culture of accountability, operational consistency, and continuous improvement.

This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.  Develops strategic plans, drives change and influences critical business outcomes.

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.

Duties Continued

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.

Perform other duties as assigned.

Education Required

Education Preferred

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.

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.

Skills

Required:

Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability.

Deep understanding of payment accuracy, claim rules, industry coding standards, reimbursement methodologies, and cost-containment strategies.

Strong analytical, financial, risk-management and problem-solving skills.

Ability to manage complex workflows, prioritize competing demands, and deliver results in high-volume environments.

Ability to build strong teams that work effectively together and collaborate across the organization

Ability to establish and maintain effective working relationships with representatives at provider organizations and with internal stakeholders.

Ability to interpret and apply complex operating instructions, state and federal regulations, and department/division procedures. Ability to understand, apply, and communicate rules, regulations and guidelines to others.

Excellent written and verbal communication skills; speaks clearly and persuasively in positive or negative situations.

Proficiency with Microsoft Office and data/reporting tools.

Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.

Demonstrated ability to make sound and timely decisions.

Demonstrated ability to adapt to changing situations and adjust strategies accordingly.

Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.

Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment.

Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information