Director, Payment Integrity (Pre-Pay Edits) - REMOTE

Molina Healthcare•Long Beach, WA

2d•Remote

About The Position

Leads and directs the team responsible for payment integrity activities, including recovery operations. Accountable for performance, quality levels, and establishing procedures and techniques that achieve optimal payment integrity operational standards and production targets. Develops and executes the strategic roadmap for payment integrity functions, ensuring alignment with enterprise objectives and regulatory standards. Oversees multiple program areas, including coordination of benefits (COB), subrogation, data mining, pre-pay edits, and payment integrity disputes, with consistent governance, methodology, and performance management across markets. Leads enterprise projects and large-scale initiatives that drive financial improvement, cost containment, and operational transformation. Partners with executive leadership and shared services functions to integrate payment integrity objectives into corporate planning, rate setting, and compliance frameworks. Establishes departmental goals, KPIs, and reporting mechanisms to measure and communicate enterprise outcomes. Provides subject matter expertise across claims processing, configuration logic, audit readiness, and vendor governance. Represents Payment Integrity at enterprise governance meetings, shared services councils, and external regulatory discussions. Oversees vendor selection, contracting, and ROI management, and champions automation, advanced analytics, and data-driven decision-making. Mentors leaders and develops succession pipelines.

Requirements

At least 8 years of experience supporting health care operations, including 5 years of payment integrity or claims experience, or an equivalent combination of relevant education and experience.
At least 3 years of management or leadership experience.
Managed care payor experience; experience in Medicare or Medicaid government-sponsored programs is preferred.
Ability to establish and maintain positive and effective work relationships with coworkers, members, providers, and customers.
Strong organizational and time-management skills, including the ability to manage simultaneous projects and tasks to meet internal deadlines.
Excellent verbal and written communication skills.
Proficiency with the Microsoft Office suite and applicable software programs.

Nice To Haves

Understanding of ICD-9/10CM and MS-, AP-, and APR-DRG reimbursement.
Electronic medical record (EMR) and medical record repository experience.
Managed care payor experience in Medicare or Medicaid government-sponsored programs.

Responsibilities

Develop and execute the strategic roadmap for payment integrity functions, aligning them with enterprise objectives and regulatory standards.
Oversee multiple program areas, including COB, subrogation, data mining, pre-pay edits, and payment integrity disputes, and ensure consistent governance, methodology, and performance management across markets.
Lead enterprise projects and large-scale initiatives that drive financial improvement, cost containment, and operational transformation.
Partner with executive leadership and shared services functions to integrate payment integrity objectives into corporate planning, rate setting, and compliance frameworks.
Establish departmental goals, KPIs, and performance reporting mechanisms to measure and communicate enterprise payment integrity outcomes.
Provide subject matter expertise across claims processing, configuration logic, audit readiness, and vendor governance to ensure accuracy and scalability.
Represent Payment Integrity at enterprise governance meetings, shared services councils, and external regulatory discussions.
Oversee vendor selection, contracting, and ROI management to maximize recovery efficiency and long-term value.
Champion innovation through automation, advanced analytics, and data-driven decision-making.
Mentor leaders and develop succession pipelines, building organizational capability and leadership readiness.
Direct the team responsible for payment integrity activities, including recovery operations, and establish procedures to achieve performance, quality, operational, and production targets.