Director, Payment Integrity

Inland Empire Health Plan•Rancho Cucamonga, CA

1d•Hybrid

About The Position

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! The Director of Payment Integrity provides strategic leadership and oversight for all Payment Integrity functions, ensuring payment accuracy, regulatory compliance, and cost containment across IEHP. This role develops and drives the vision and strategy for payment integrity programs and operational excellence. The Director partners across the enterprise to optimize reimbursement, prevent fraud, waste, abuse, and improve member affordability. This role is critical to ensuring the financial sustainability and regulatory compliance of the organization by preventing, identifying, and recovering inappropriate healthcare payments across all lines of business, including Medi-Cal, Medicare Advantage, and Commercial products. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

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
Bachelor's degree in Business Administration, Accounting, or Healthcare from an accredited institution required
Comprehensive knowledge and understanding in the following areas:
Rules and regulations governing Medi-Cal benefits and claims adjudication practices and procedures
Coding Knowledge for ICD-10, CPT, or Healthcare Common Procedure Coding Syste
Principles and techniques of supervision and training
Negotiation and relationship management
Process improvement and business process design
Data entry involving computer keyboards and screens
Skill in word processing and presentation software
Microcomputer literacy preferred
Advanced skill in project management
Proficiency in spreadsheet, statistical analysis, query / data mining, and business intelligence software
Proven ability to:
Maintain confidentiality and privacy
Communicate professionally to both internal and external stakeholders
Establish, contribute, and maintain a positive and productive work environment
Plan, organize, and manage the work of all assigned personnel

Nice To Haves

Medi-Cal and/or Medicare claims experience
Master’s degree in a related field from an accredited institution

Responsibilities

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: a. Pre- and post-payment data mining b. Clinical reviews c. Subrogation d. Itemized bill reviews e. Coordination of Benefits (COB) f. Partnering 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: g. Pre- and Post-Payment Coordination of Benefits h. Pre- and Post-Payment Data Mining i. Pre- and Post-Payment Clinical Reviews j. Subrogation and Third-Party Liability Recovery k. 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: l. Trending unsolicited refunds to identify systemic issues m. Collaborating with Claims and Configuration to improve adjudication logic n. 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.