L.A. Care Health Plan · 3 hours ago
Director, Payment Integrity
Los Angeles, CA
Full-time
Onsite
Director/Executive
$135K/yr - $216K/yr
7+ years expL.A. Care Health Plan is the nation’s largest publicly operated health plan, serving low-income residents in Los Angeles County. The Director, Payment Integrity is responsible for defining and leading the payment integrity operating model, ensuring accuracy in provider payments and minimizing inappropriate spending while overseeing a multi-functional team to enhance operational efficiency.
FitnessGovernmentHealth Care
Responsibilities
Strengthens accuracy, prevents financial leakage, and ensures upstream and downstream controls operate as a cohesive system
Refines and enhances disciplined processes, improves the sustainability of controls, and leverages data to identify and mitigate risks before they impact members, providers, or financial performance
Through cross-functional collaboration, structured execution, and proactive problem-solving, enhances the organization’s ability to manage medical spend responsibly and ensure accurate, compliant payment outcomes
Develops and executes the Payment Integrity strategy, ensuring alignment with enterprise financial, operational, and regulatory priorities
Leads a comprehensive operating model that integrates pre-pay, post-pay, clinical editing, cost-avoidance, data mining, recovery operations, COB, and TPL functions
Designs and maintains governance frameworks, policies, workflows, and quality standards that strengthen preventive controls and reduce rework
Ensures consistent application of rules, benefit interpretation, pricing methodologies, and contract terms across all Payment Integrity activities
Oversees the development and implementation of pre-payment controls including clinical editing, code auditing, configuration recommendations, automated and algorithm-based edits, and pre-pay clinical and non-clinical reviews
Partners with cross functional teams to implement upstream changes that prevent recurring payment errors and reduce operational burden
Leads initiatives that increase automation, improve first-pass accuracy, and reduce the volume of post-pay recoveries
Oversees identification, validation, and recovery of overpayments across solicited and unsolicited sources, ensuring accuracy, transparency, and regulatory compliance
Leads recovery operations, including provider outreach, appeals support, repayment management, and reconciliation of recovery outcomes
Ensures post-pay findings feed into proactive improvements and preventive interventions, reducing future inappropriate payments
Directs internal data mining and analytical review functions to identify billing anomalies, emerging risk patterns, and cost avoidance opportunities
Partners with Analytics leaders to develop predictive models, dashboards, and trending tools that support smarter interventions and program scalability
Translates analytical insights into operational or system changes that reduce leakage and strengthen the accuracy of initial payment decisions
Oversees COB and TPL programs to ensure correct payer order, maximize cost avoidance, and support regulatory reporting requirements
Ensures timely, accurate, and complete responses to inquiries from DHCS or other regulatory bodies
Strengthens processes to reduce inappropriate payments that result from eligibility, coordination, or primary payer errors
Manages relationships with Payment Integrity vendors, ensuring contract compliance, performance against SLAs, timely implementation of new programs, and accurate financial reconciliation
Assesses vendor performance and identifies opportunities to optimize or expand program impact
Ensures vendor partners follow appropriate standards, quality controls, and documentation expectations
Ensures Payment Integrity processes meet all regulatory and contractual requirements across Medicaid, Medicare, Commercial, and Exchange lines of business
Leads or supports responses to audits, inquiries, corrective action plans, and regulatory reviews related to payment accuracy
Partners with QA to validate accuracy and consistency of Payment Integrity findings, recoveries, and interventions
Collaborates with Claims Administration, Configuration, Provider Network Management, EDI, Compliance, and Finance to address systemic issues and improve end-to-end payment outcomes
Advises leadership and internal partners on payment accuracy trends, root-cause drivers, provider impact, and mitigation strategies
Builds strong relationships with provider partners and communicates clearly on payment rules, system behaviors, and corrective actions
Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees
Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals
Develops, and manages budgets, utilizing resources effectively
Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals
Identifies and actualizes enhancements to support company vision
Develops and maintains relationships with key stakeholders
Leads discussions on policy operationalization and oversees key policy perspective sharing
Oversees succession planning to build technical expertise and operational consistency
Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement
Qualification
Required
Bachelor's Degree
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
Strong analytical, financial, risk-management and problem-solving skills
Ability to manage complex workflows, prioritize competing demands, and deliver results in high-volume environments
Ability to build strong teams that work effectively together and collaborate across the organization
Ability to establish and maintain effective working relationships with representatives at provider organizations and with internal stakeholders
Ability to interpret and apply complex operating instructions, state and federal regulations, and department/division procedures
Ability to understand, apply, and communicate rules, regulations and guidelines to others
Excellent written and verbal communication skills; speaks clearly and persuasively in positive or negative situations
Proficiency with Microsoft Office and data/reporting tools
Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization
Demonstrated ability to make sound and timely decisions
Demonstrated ability to adapt to changing situations and adjust strategies accordingly
Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change
Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment
Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations
Preferred
Master's Degree in Business Administration or Related Field
Experience developing and overseeing COB/TPL programs
Experience engaging with regulators, responding to audits, and overseeing and managing vendor partners
Experience implementing predictive analytics or algorithm-based Payment Integrity solutions
Benefits
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)
Company
L.A. Care Health Plan
L.A. Care’s mission is to provide access to quality health care for L.A.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Melanie Rainer
Chief Strategy and Transformation Officer
Recent News
MarketScreener
2025-08-27
2025-08-04
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