Director, Payment Integrity

What you can expect! 

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.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• 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

Strategic Development & Leadership

1. Build and operationalize an internal Payment Integrity Unit, including talent strategy, workflows, and performance metrics.

2. 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.

3. Establish governance and oversight structures to ensure accountability, transparency, and compliance with regulatory requirements.

Strategic Development & Leadership

4. Lead vendor selection, contracting, implementation, and ongoing performance management including maintaining a minimum 4:1 return-on-investment (ROI).

5.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

Operational Oversight

6. 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

7. 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

Cross-Functional Collaboration

8. Partner with internal departments (Claims, Finance, IT, Utilization Management, Provider Network Management, Compliance) to socialize initiatives and embed payment integrity strategies into enterprise initiatives.

9. Work with Provider Network Management to support provider education and training on compliant billing practices under state, federal, and commercial guidelines.

10. Collaborate with IT and Configuration to implement system edits, automation, and analytics tools that support insourced capabilities.

Analytics & Reporting

11. 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.

12. Analyze data to identify new opportunities for cost avoidance and recovery.

13. Present findings and strategic recommendations to executive leadership.

14. Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Education & Requirement

• 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
  • Preferred: Medi-Cal and/or Medicare claims experience
• Bachelor's degree in Business Administration, Accounting, or Healthcare from an accredited institution required
  • Preferred: Master’s degree in a related field from an accredited institution

Key Qualifications

• 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
    

Start your journey towards a thriving future with IEHP and apply TODAY!

This position is on a hybrid work schedule. (Monday & Friday - remote, Tuesday – Thursday onsite in Rancho Cucamonga, CA.)