Senior Payment Integrity Program Development Specialist

Inland Empire Health Plan•Rancho Cucamonga, CA

1d•$80,059 - $106,059•Hybrid

About The Position

The Senior Payment Integrity Program Development Specialist serves as a subject matter expert driving the research, analysis, and development of Payment Integrity initiatives that strengthen payment accuracy, reduce overpayments, and ensure regulatory and contractual compliance. This role evaluates medical cost trends, claims patterns, and industry developments to create and manage a robust backlog of audit concepts and vendor-based solutions. This position determines concept feasibility and financial impact, refines, and documents logic, and partners with Clinical, Policy, and the Special Investigations Unit (SIU) to transform findings into actionable outcomes. This Senior Payment Integrity Program Development Specialist also assesses existing pre and post payment audit programs to enhance fraud, waste, and abuse (FWA) detection, while guiding cost avoidance improvements across Payment Integrity operations. The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

Minimum of five (5) years of relevant experience required
Experience creating concept logic, tracking performance, and working with external vendors required
Experience with SQL or data mining. Experience in complex claims analytics and trend evaluation
Bachelor’s degree in business, health administration, or a related field from an accredited institution required
In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position
This experience is in addition to the minimum years listed in the Experience Requirements above.
Strong knowledge and deep understanding of: The claims lifecycle, including coding (ICD-10, CPT, DRG) and reimbursement policies (NCCI, correct coding, modifiers, medical necessity, frequency limits, RBRVS, etc.)
Managed Medi-Cal policies, DHCS updates, CMS guidelines
Provider billing practices and common coding/bundling issues
Payment methodologies and share of cost (Medi-Cal Rates, APR-DRG, Per diem, contractual percent of charge)
Query logic development from contracts, provider manuals and billing and coding sources
False positive identification and root cause analysis of query logic to identify and remediate errors in configuration
Claims adjudication platforms and data file layouts
Strong skills in SQL and Microsoft Excel
Communication and presentation skills
Proven ability to: Analyze complex data sets for claims irregularities using tools like SQL or Excel
Move from data insights to create and implement logic for concept development
Manage competing priorities

Nice To Haves

Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred

Responsibilities

Conduct proactive research using medical cost data, claims trends, CMS/OIG updates, and industry changes to identify new Payment Integrity concept opportunities.
Analyze complex claims data sets to detect irregularities, validate assumptions, and support high impact concept development using tools such as SQL or Excel.
Determine financial impact, feasibility, and compliance alignment for proposed concepts, ensuring adherence to regulatory and contractual requirements.
Build, maintain, and prioritize a backlog of potential initiatives based on projected savings, operational effort, and compliance risk.
Develop and refine concept logic, ensuring clarity, accuracy, and readiness for production deployment.
Partner with Clinical teams, Policy, and SIU to validate findings, strengthen recommendations, and support cross functional implementation.
Assess and improve existing pre and post payment vendor audit programs, identifying opportunities to enhance FWA detection and prevention.
Lead the development of cost avoidance strategies and solutions that optimize pre payment editing and reduce claim inaccuracies.
Coordinate with external vendors to evaluate concepts, review performance results, and support ongoing program optimization.
Prepare and present comprehensive analytical findings, financial impact assessments, and concept recommendations to leadership.
Document claims coding (ICD 10, CPT, DRG) processes, reimbursement methodologies, and industry payment policies to support accurate concept design.
Perform any other duties as required to ensure Health Plan operations and department business needs are successful.