Manages and leads critical components of L.A. Care’s enterprise Payment Integrity program
Oversees the design, execution, and continuous refinement of pre-payment and post-payment accuracy activities
Ensures PI programs are executed consistently, documented clearly, and aligned with regulatory, contractual, and financial expectations
Leads daily operations of pre-pay and post-pay PI activities, ensuring accuracy, timeliness, and effective case management
Oversees prospective review programs including clinical editing, code auditing, algorithm-driven controls, and provider contract/benefit interpretation
Ensures post-pay functions, including data mining, recovery validation, provider outreach, and reconciliation, are accurate, transparent, and compliant
Establishes standardized workflows, documentation, and quality review expectations across all PI teams.
Oversees identification and validation of overpayments and underpayments from solicited/unsolicited sources, analytics, and vendor partners
Partners with key stakeholders to implement upstream corrections and reduce recurring defects
Ensures operational execution of vendor-driven PI programs, ensuring strong Service level agreement (SLA) performance, validated results, and accurate financial reporting.

Requirements

Bachelor's Degree
At least 6 years of Payment Integrity, Program Integrity, medical cost containment, Fraud Waste and Abuse (FWA), data mining, claim accuracy, or related experience
At least 5 years of experience in leading staff, Supervising and/or managing staff
Experience leading teams, projects, initiatives, and cross-functional groups
Experience in Medicaid, Medicare, and Commercial managed care lines of business
Experience in pre-pay and/or post-pay review, edit development, recovery operations, or claim logic development
Experience interpreting provider contracts, payment methodologies, and managed care benefit structures
Experience handling complex claim review, root-cause evaluation, and adhering to regulatory TAT requirements
Experience working with COB and Third-Party Liability (TPL) claims in a managed care setting
Experience with vendor-managed PI programs.
Preferred: Experience applying predictive analytics or algorithm-based PI solutions
Preferred: Experience with SQL, BI tools, or data mining platforms.

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 IntegrityProgram Integritymedical cost containmentFraud Waste and Abusedata miningclaim accuracypre-pay reviewpost-pay reviewedit developmentrecovery operations

Soft skills

leadershipstaff managementcross-functional collaborationproject managementcommunicationproblem-solvinganalytical thinkingstakeholder engagementquality assurancecase management

Certifications

Bachelor's Degree