Senior Manager, Payment Integrity Operations

L.A. Care Health Plan•Los Angeles, CA

About The Position

The Senior Manager, Payment Integrity (PI) Operations, manages and leads critical components of L.A. Care’s enterprise Payment Integrity program, overseeing the design, execution, and continuous refinement of pre-payment and post-payment accuracy activities. This position integrates operational management with analytic, regulatory, and contract-driven development to prevent inappropriate payments, strengthen upstream controls, and ensure accurate financial outcomes across all lines of business. The Senior Manager manages multi-functional teams responsible for prospective edit development, clinical and non-clinical pre-payment reviews, retrospective audits, overpayment/underpayment identification, recovery operations, and pipeline management. This position ensures PI programs are executed consistently, documented clearly, and aligned with regulatory, contractual, and financial expectations. The Senior Manager works closely with cross-functional stakeholders to translate insights into actionable system changes and preventive modifications. The Senior Manager serves as the operational driver for Payment Integrity interventions, ensuring programs scale effectively, are audit-ready, and deliver measurable reductions in inaccurate or wasteful spend. Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.

Requirements

Bachelor's Degree In lieu of degree, equivalent education and/or experience may be considered.
At least 6 years of Payment Integrity, Program Integrity, medical cost containment, Fraud Waste and Abuse (FWA), data mining, claim accuracy, or related experience.
At least 5 years of experience in leading staff, Supervising and/or managing staff.
Experience leading teams, projects, initiatives, and cross-functional groups.
Experience in Medicaid, Medicare, and Commercial managed care lines of business.
Experience in pre-pay and/or post-pay review, edit development, recovery operations, or claim logic development.
Experience interpreting provider contracts, payment methodologies, and managed care benefit structures.
Experience handling complex claim review, root-cause evaluation, and adhering to regulatory TAT requirements
Experience working with COB and Third-Party Liability (TPL) claims in a managed care setting.
Experience with vendor-managed PI programs.
Strong understanding of adjudication, coding, and the application of Division of Financial Responsibility (DOFR) to claims processing.
Extensive knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-10, DRG/ Ambulatory Payment Classification (APC), and pricing methodologies.
Understanding of benefit interpretation, contract terms, and payment rules.
Strong analytical, investigative, financial, and operational skills.
Exceptional written and verbal communication skills, including executive communication and the ability to translate technical findings into actionable recommendations.
Advanced project leadership, workflow management, and prioritization skills.
Ability to collaborate with internal and external stakeholders at all levels.
Proven problem-solving skills and ability to translate knowledge to the department.
Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.
Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.
Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.
Must have a deep understanding of financial principles.
Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.
Demonstrated ability to make informed decisions.
Strong verbal, written communication and presentation skills.
Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.
Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

Nice To Haves

Master's Degree in Business Administration or Related Field
Experience applying predictive analytics or algorithm-based PI solutions.
Experience with SQL, BI tools, or data mining platforms.
Knowledge of SIU/FWA methodologies and risk indicators.
Experience with SQL, BI tools, or data mining platforms.
Certified Professional Coder (CPC) designation by the American Academy of Professional Coders

Responsibilities

Leads daily operations of pre-pay and post-pay PI activities, ensuring accuracy, timeliness, and effective case management.
Oversees prospective review programs including clinical editing, code auditing, algorithm-driven controls, and provider contract/benefit interpretation.
Ensures post-pay functions, including data mining, recovery validation, provider outreach, and reconciliation, are accurate, transparent, and compliant.
Establishes standardized workflows, documentation, and quality review expectations across all PI teams.
Ensures Payment Integrity operates as a disciplined, analytically driven, and preventive control function.
Strengthens the reliability of claims processing, increases automation and cost avoidance, manages complex PI workflows, and translates regulatory and contract-driven requirements into systematic, sustainable accuracy improvements.
Oversees development, refinement, and implementation of new edits, rules, and clinical/non-clinical logic that reduce future payment errors.
Translates regulatory updates, provider contract terms, benefit changes, and emerging industry standards into edit or algorithm recommendations.
Manages the PI pipeline of prospective initiatives, ensuring strong prioritization, impact modeling, and timely deployment.
Partners with key stakeholders to implement upstream corrections and reduce recurring defects.
Ensures prospective controls improve auto-adjudication, accuracy, and reduction of rework.
Oversees identification and validation of overpayments and underpayments from solicited/unsolicited sources, analytics, and vendor partners.
Ensures recoveries follow compliant workflows, including provider notification, appeal support, repayment management, and financial reconciliation.
Ensures post-pay insights translate into upstream corrective actions, edit changes, or preventive improvements.
Oversees development of operational processes that strengthen coordination between internal recovery teams and external vendors.
Directs analytic and data mining efforts to detect billing anomalies, emerging risk patterns, and high-impact cost avoidance opportunities.
Partners with enterprise analytics to refine predictive modeling, trending dashboards, and reporting frameworks.
Ensures analytical findings convert into operational interventions, policy updates, or system changes.
Identifies high-risk providers, services, or claims behaviors requiring new controls or deeper review.
Ensures PI programs align with federal, state, and contractual requirements for all lines of business.
Interprets regulatory updates and directs teams to integrate changes into rules, workflows, and edit development.
Ensures that benefit structures, contract terms, and pricing methodologies are correctly reflected in both pre- and post-pay activities.
Partners with Compliance and SIU on cases requiring heightened review or escalated investigation.
Oversees operational execution of vendor-driven PI programs, ensuring strong Service level agreement (SLA) performance, validated results, and accurate financial reporting.
Supports vendor onboarding, implementation, testing, and algorithm or rule customizations.
Ensures internal teams coordinate effectively with external partners across pre-pay and post-pay programs.
Partners with cross-functional key stakeholders to resolve system issues and strengthen upstream accuracy.
Serves as an advisor to internal partners on PI trends, risk areas, provider behavior insights, and recommended control changes.
Ensures PI findings are shared proactively and used to influence broader operational and configuration improvements.
Manages staff and the day-to-day activities in the department.
Participates in the department budgeting process.
Responsible for scheduling, training, performance, corrective actions, mentoring, developing of the team(s).
Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals.
Mentors and develops staff, building technical and problem-solving skills across the team.
Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs.
Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
Responsible for overseeing and managing the budgets of their respective departments.
Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.
Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.
Perform other duties as assigned.