Director, Payment Integrity (Analytics & Strategy) - REMOTE

Molina Healthcare•Long Beach, CA

3d•Remote

About The Position

Responsible for leading the strategy, governance, implementation, maintenance, and optimization of the organization’s Payment Integrity post-pay data mining program. The Director leads a team of Business Analysts, Data Engineers, and Data Analysts who develop and maintain concept requirements, analytical logic, and workflow solutions supporting Molina’s portfolio of post-pay concepts. The role provides business and technical leadership across the concept lifecycle, translating healthcare reimbursement policies, coding requirements, and payment integrity opportunities into accurate, scalable, and maintainable analytical solutions. The Director serves as a key liaison between Health Plans and Executive Leadership teams and oversees a high-volume, fast-paced environment supporting concept lifecycle management, stakeholder engagement, and continuous improvement initiatives.

Requirements

At least 8 years of experience supporting health care operations, including 5 years of payment integrity/claims experience, or an equivalent combination of relevant education and experience.
At least 3 years of management/leadership experience.
Managed care payor experience; Medicare/Medicaid government-sponsored program experience 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

Advanced knowledge of SQL and experience reviewing or providing oversight of production-level SQL logic.
Hands-on experience with Databricks and Azure DevOps, including notebooks, workflows, data pipelines, or related development and analytical capabilities.
Knowledge of CPT, HCPCS, ICD-10-CM, ICD-10-PCS, NCCI, DRG, and reimbursement methodologies.
Strong understanding of healthcare claims processing, reimbursement methodologies, coding systems, and payment integrity principles.
5 years of leadership experience managing teams responsible for payment integrity analytics, claim configuration, claims auditing, or related analytical functions.

Responsibilities

Develop and execute the strategic roadmap for the post-pay payment integrity concept portfolio, aligned with organizational financial, operational, and regulatory objectives.
Oversee the end-to-end lifecycle of payment integrity concepts and ensure consistent governance, methodology, and performance management across markets.
Provide technical oversight of concept development and maintenance, including SQL-based analytical logic, Databricks solutions, and Azure DevOps work management.
Lead enterprise projects and large-scale initiatives that drive financial improvement, cost containment, and operational transformation.
Lead, mentor, and develop Business Analysts, Data Engineers, and Data Analysts responsible for concept research, documentation, technical development, implementation, and ongoing maintenance.
Establish departmental goals, KPIs, and performance reporting mechanisms to measure and communicate enterprise payment integrity outcomes.
Represent Payment Integrity at enterprise governance meetings, shared services councils, and external regulatory discussions.
Champion innovation through automation, advanced analytics, and data-driven decision-making.
Establish performance expectations, development plans, and succession strategies that support organizational growth and talent development.
Translate healthcare reimbursement policies, coding guidelines, and business opportunities into actionable business requirements and analytical solutions.
Support organizational initiatives that improve payment accuracy, reduce administrative burden, and maximize recovery opportunities.
Ensure compliance with regulatory requirements, reimbursement policies, coding standards, and organizational governance practices.
Monitor industry trends, regulatory changes, and emerging payment integrity opportunities to inform strategic direction and concept development priorities.