Director,Integrity Job Rancho Cucamonga area,California USA,Healthcare

Position: Director, Payment Integrity

Overview

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.

Additional Benefits

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

Key Responsibilities

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

Develop, execute, and sustain a strategic roadmap for in sourcing 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:

Pre- and post-payment data mining
Clinical reviews
Subrogation
Itemized bill reviews
Coordination of Benefits (COB)
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:

Pre- and Post-Payment Coordination of Benefits
Pre- and Post-Payment Data Mining
Pre-and Post-Payment Clinical Reviews
Subrogation and Third-Party Liability Recovery
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:

Trending unsolicited refunds to identify systemic issues
Collaborating with Claims and Configuration to improve adjudication logic
Mitigating future over payments 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,…


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Job Posting Language

Director, Integrity