Healthpartners-posted 4 months ago
Full-time • Senior
Bloomington, MN
Professional, Scientific, and Technical Services

HealthPartners is hiring a Director of Payment Integrity. The Director of Payment Integrity will lead the strategic development, implementation, and oversight of payment integrity programs across all lines of business, including Fully Insured Commercial, Self-Funded, Medicare Advantage, and Medicaid lines of business. This role is responsible for ensuring accurate claims payment, identifying and recovering inappropriate payments, and preventing future payment errors through data-driven insights, cross-functional collaboration, and vendor partnerships. The Director will play a critical role in safeguarding financial performance while promoting compliance, operational excellence, and member/provider satisfaction.

  • Develop and execute a comprehensive payment integrity strategy aligned with organizational goals and regulatory requirements.
  • Lead cross-functional initiatives to enhance claims accuracy, reduce waste, and improve cost containment.
  • Manage end-to-end payment integrity operations including pre-pay and post-pay audits, fraud/waste/abuse detection, coordination of benefits, and third-party liability.
  • Oversee vendor relationships and performance, ensuring accountability and ROI.
  • Leverage advanced analytics to identify trends, root causes, and opportunities for improvement.
  • Develop and present executive-level reporting on savings, recoveries, and program impact.
  • Ensure adherence to federal and state regulations, including CMS and Medicaid guidelines.
  • Collaborate with Legal, Compliance, and SIU teams to mitigate risk and ensure audit readiness.
  • Build and lead a high-performing team of analysts, auditors, and program managers.
  • Foster a culture of continuous improvement, innovation, and accountability.
  • Bachelor's degree in Business Administration, Healthcare Administration, Finance, or a related field.
  • Minimum of 8 years of progressive experience in healthcare payment integrity, claims operations, or healthcare finance, with at least 3 years in a leadership or management role.
  • Strong understanding of health plan operations, claims processing, and payment integrity functions.
  • Working knowledge of regulatory requirements for Medicare Advantage, Medicaid, and Commercial lines of business.
  • Proven ability to lead cross-functional teams and manage complex projects.
  • Proficiency in data analysis and reporting tools (e.g., Excel, SQL, Tableau).
  • Excellent communication, negotiation, and stakeholder management skills.
  • Ability to work in a fast-paced, matrixed environment with competing priorities.
  • Strong interpersonal and collaborative skills to lead and influence teams at all levels of the organization.
  • Solid analytical, project and financial management skills.
  • Ability to offer creative, cost-effective alternatives and options to solve problems and meet customer needs.
  • Strong oral and written communications.
  • Master's degree in Healthcare Administration, Business, Public Health, or a related field.
  • 10+ years of experience in payment integrity or healthcare cost containment, with 5+ years in a senior leadership role overseeing multi-line health plan operations (Commercial, Self-Funded, Medicare Advantage, Medicaid).
  • Experience managing external vendors and third-party payment integrity solutions.
  • Preferred certifications: AHFI (Accredited Health Care Fraud Investigator), CHC (Certified in Healthcare Compliance), CFE (Certified Fraud Examiner), Six Sigma or Lean certification for process improvement.
  • Deep expertise in payment integrity strategies including pre-pay and post-pay audits, FWA detection, COB, and TPL.
  • Familiarity with CMS and state Medicaid audit protocols and compliance frameworks.
  • Advanced analytical and strategic thinking skills with the ability to translate data into actionable insights.
  • Experience with enterprise claims platforms and integration with payment integrity tools.
  • Demonstrated success in driving cost savings and operational improvements through innovation and collaboration.
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