Senior Manager, Integrity

Position: Senior Manager, Payment Integrity
* Lead and manage Payment Integrity operations, including pre-pay edits, post-pay audits, recoveries and payment validation
* Translate PI strategy into operational execution with clear goals, KPIs, and accountability
* Build, develop, and mentor staff; establish clear expectations and performance standards
* Serve as a subject matter expert and thought leader on payment integrity best practices within managed care environment
* Oversee pre-payment and post-payment review, including clinical and coding audits, fraud, waste and abuse prevention and retrospective analysis
* Ensure timely identification, validation and recovery of over payments in accordance with state, federal and contractual requirements
* Partner with Claims Operations and Configuration to enhance auto-adjudication accuracy and claims editing controls
* Monitor PI inventory, cycle times, recovery rates and financial impact
* Manage PI vendors including performance monitoring, issue escalation and contract compliance
* Review vendor findings, savings methodologies, and ROI to ensure accuracy and transparency
* Lead corrective action plans (CAPs) and continuous improvement initiatives related to PI findings
* Ensure PI operations are compliant with DHCS, CMS and managed care regulations and Gold Coast Health Plans policies
* Supports internal and external audits, including DHCS readiness reviews and financial audits
* Maintain strong documentation, controls and audit trails for PI activities
* Identify systemic payment risks and recommend corrective actions
* Collaborate with Claims, Finance, Compliance, Provider Network, IT and Configuration teams to resolve root-cause issues
* Provide PI insights to leadership to support decision-making, budgeting and risk mitigation
* Support provider education and remediation efforts related to payment integrity findings
* Develop and maintain dashboards and reports on PI performance, recoveries, trends and risk areas
* Present PI results, risks and opportunities to senior leadership
* Drive data-driven decision-making and continuous operational improvement
* Knowledge of:  + Principles and practices of health care service delivery and managed care, Medi-Cal eligibility, and benefits. Medical billing/coding (CPT, HCPCS, ICD-9 and ICD-10); COB/TPL regulations and guidelines.  + Claims operations and supporting information systems; experience in developing and tracking performance metrics.  + Principles, practices, techniques, and theories of claims administration and customer service for a government agency serving a diverse social and ethnic population.  

+ State and federal regulations as they relate to Medi-Cal managed care and other related business and policies governing managed care issues.
* Perform such other duties as assigned.
* Enter responsibilities.
* Bachelor's Degree (four-year college or technical school):
Preferred
* Demonstrated experience leading teams, projects, initiatives, and cross‑functional groups.
* Experience working within Medicaid and Medicare managed care programs.
* Experience with pre‑pay and/or post‑pay review, edit development, recovery operations, or claim logic development.
* Ability to interpret provider contracts, payment methodologies, and managed care benefit structures.
* Experience conducting complex claim reviews, performing root‑cause analysis, and meeting regulatory turnaround requirements.
* Experience with Coordination of Benefits (COB) and Third‑Party Liability (TPL) claims in a managed care environment.
* Experience managing or collaborating with vendor‑managed Payment Integrity programs.
* Experience applying predictive analytics or algorithm‑based PI solutions.

- Minimum 6 years of experience in one or more of the following areas:  
* Payment Integrity or Program Integrity  
* Medical cost containment  
* Fraud, Waste, and Abuse (FWA)  
* Data mining or claim accuracy  
* Related healthcare claims or analytics functions
- Working knowledge of:  
* Medicaid and Medicare managed care regulations  
* Payment Integrity methodologies and industry best practices  
* Claims processing systems, benefit configuration, and provider reimbursement methodologies
- Ability to:  
* Analyze complex…