Director, Payment Integrity
L.A. Care Health Plan
full-time
Posted on:
Location Type: Office
Location: Los Angeles • California • United States
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Salary
💰 $135,136 - $216,218 per year
Job Level
About the role
- Defines the payment integrity operating model and is accountable for prevention, governance, analytics, risk reduction, and sustained accuracy across all prepay and post pay activity.
- Responsible for designing, leading, and continuously improving the end-to-end Payment Integrity program.
- Ensures the accuracy of provider payments, minimizes inappropriate spend, and strengthens preventive and detective controls across all lines of business.
- Partners closely with cross-functional teams and external vendors to ensure sustained, measurable impact on medical cost reduction, accuracy, audit readiness, and provider experience.
- Oversees clinical editing, data mining, cost-avoidance strategies, recovery operations, COB, TPL, and analytical review of billing and payment patterns.
- Develops strategic plans, drives change, and influences critical business outcomes.
Requirements
- 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.
- 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.
- Proficiency with Microsoft Office and data/reporting tools.
Benefits
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
Payment IntegrityFraud preventionWaste preventionAbuse preventionClaims AccuracyMedical Cost ContainmentCost-avoidance strategiesClinical editingData miningRecovery operations
Soft skills
Interpersonal leadershipMotivating talentDeveloping talentDriving accountability