Director, Payment Integrity
Job Description
Morgan Consulting Resources, Inc. has been retained by L.A. Care Health Plan to conduct the search for a Director, Payment Integrity. This position is based in Los Angeles, CA, with a hybrid schedule.
About L.A. Care Health Plan
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.
L.A. Care continues to operate in an increasingly complex and highly regulated environment, where Payment Integrity plays a critical role in ensuring financial stewardship, regulatory compliance, and operational accuracy. As the organization continues to evolve, there is a strong emphasis on strengthening preventive controls, improving first-pass claims accuracy, and reducing reliance on post-pay recovery. This function is central to minimizing inappropriate spend, identifying systemic issues, and driving sustainable improvements across the claims and payment ecosystem.
About the Director, Payment Integrity
Reporting to the Senior Director, Core Administrative Operations, the Director, Payment Integrity will define and lead the organization’s Payment Integrity operating model, with accountability for prevention, governance, analytics, and sustained payment accuracy across all lines of business.
This role is responsible for designing, implementing, and continuously improving a comprehensive, end-to-end Payment Integrity program that integrates pre-pay and post-pay activities, including clinical editing, data mining, cost avoidance, recovery operations, COB, and TPL. A key focus of this role is strengthening upstream controls to prevent errors before they occur, while ensuring effective downstream recovery and feedback loops that drive long-term operational improvement.
Operating in close alignment with Configuration and Claims Administration, this leader will play a central role in advancing L.A. Care’s broader transformation of core administrative operations. The Director will identify systemic drivers of payment inaccuracy and partner cross-functionally to implement scalable solutions that improve first-pass accuracy, reduce rework, and enhance provider experience.
The Director will lead a multi-functional team and oversee vendor partnerships, ensuring performance, accountability, and measurable impact. This is a highly visible leadership role requiring a builder’s mindset, with a strong focus on helping lead the organization through a critical evolution of its Payment Integrity function. Over the next 12–18 months, the Director will play a key role in advancing a more balanced approach across pre-pay prevention and post-pay recovery, shaping a more proactive, effective, and sustainable operating model.
Education & Experience Requirements
L.A. Care’s mission is to provide access to quality healthcare for Los Angeles County’s vulnerable and low-income residents to support the safety net required to achieve that purpose.
L.A. Care’s vision is a healthy community in which all have access to the health care they need.
Organizational Values:
Salary range: $135,136 (min.) - $175,676 (mid.) - $216,218 (max.) with annual bonus potential. The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
Benefits: Paid Time Off (PTO); tuition reimbursement; retirement plans; medical, dental & vision; wellness program; volunteer time off (VTO).
Contact:
Erica Eikelboom, Principal & Executive Search Consultant
Morgan Consulting Resources
erica@morganconsulting.com
POSITION DESCRIPTION
Company: L.A. Care Health Plan
Position: Director, Payment Integrity
Position Type: Non-Clinical
Position Level: Director
FLSA Designation: Exempt
Location: Los Angeles, CA (hybrid)
Job Summary
The Director, Payment Integrity defines the payment integrity operating model. As owner, is accountable for prevention, governance, analytics, risk reduction and sustained accuracy across all prepay and post pay activity. This position is responsible for designing, leading, and continuously improving the end-to-end Payment Integrity program. This position ensures the accuracy of provider payments, minimized inappropriate spend, and strengthens preventive and detective controls across all lines of business. The Director oversees clinical editing, data mining, cost-avoidance strategies, recovery operations, coordination of benefits (COB), third-party liability (TPL), and analytical review of billing and payment patterns.
The Director sustains a Payment Integrity operating model that prevents incorrect payments before they occur, improves the reliability of claims processing through strong upstream controls, identifies systemic issues contributing to payment errors, and drives operational, configuration, or provider-facing changes that improve accuracy over time. This leader partners closely with cross-functional teams and external vendors to ensure sustained, measurable impact on medical cost reduction, accuracy, audit readiness, and provider experience.
The Director leads a multi-functional team that includes internal data mining, clinical review, overpayment recovery, prospective pre-payment programs, and vendor management. The Director is responsible for building analytic and operational rigor, embedding standardized processes, and fostering a culture of accountability, operational consistency, and continuous improvement.
This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Develops strategic plans, drives change and influences critical business outcomes.
Essential Duties and Responsibilities
Required:
Light: (Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly. Requires walking, standing to a significant degree, dexterity of hands and fingers to operate a variety of standard office equipment. Requires sitting most of the time, but entails pushing and/or pulling of arm or leg controls. The job may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.)
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About L.A. Care Health Plan
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.
L.A. Care continues to operate in an increasingly complex and highly regulated environment, where Payment Integrity plays a critical role in ensuring financial stewardship, regulatory compliance, and operational accuracy. As the organization continues to evolve, there is a strong emphasis on strengthening preventive controls, improving first-pass claims accuracy, and reducing reliance on post-pay recovery. This function is central to minimizing inappropriate spend, identifying systemic issues, and driving sustainable improvements across the claims and payment ecosystem.
About the Director, Payment Integrity
Reporting to the Senior Director, Core Administrative Operations, the Director, Payment Integrity will define and lead the organization’s Payment Integrity operating model, with accountability for prevention, governance, analytics, and sustained payment accuracy across all lines of business.
This role is responsible for designing, implementing, and continuously improving a comprehensive, end-to-end Payment Integrity program that integrates pre-pay and post-pay activities, including clinical editing, data mining, cost avoidance, recovery operations, COB, and TPL. A key focus of this role is strengthening upstream controls to prevent errors before they occur, while ensuring effective downstream recovery and feedback loops that drive long-term operational improvement.
Operating in close alignment with Configuration and Claims Administration, this leader will play a central role in advancing L.A. Care’s broader transformation of core administrative operations. The Director will identify systemic drivers of payment inaccuracy and partner cross-functionally to implement scalable solutions that improve first-pass accuracy, reduce rework, and enhance provider experience.
The Director will lead a multi-functional team and oversee vendor partnerships, ensuring performance, accountability, and measurable impact. This is a highly visible leadership role requiring a builder’s mindset, with a strong focus on helping lead the organization through a critical evolution of its Payment Integrity function. Over the next 12–18 months, the Director will play a key role in advancing a more balanced approach across pre-pay prevention and post-pay recovery, shaping a more proactive, effective, and sustainable operating model.
Education & Experience Requirements
- Bachelor’s degree required. In lieu of degree, equivalent education and/or experience may be considered.
- Master’s degree in business administration or related field preferred.
- 7+ years of experience in a system configuration or managed care operations involving core administrative platforms (e.g. Cognizant QNXT).
- 5+ years of experience leading, supervising and/or managing staff in technical or operational environments.
- Significant experience configuring benefits, pricing methodologies, provider payment logic, and related adjudication rules.
- 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.
- Advanced knowledge of and experience with American Health Information Management Association (AHIMA) coding standards.
- Knowledge of and experience with utilizing Systems Development Life Cycle (SDLC), configuration change management methodologies, testing protocols, document standards, and best practices.
- Experience supporting audits, corrective actions, and regulatory reviews.
L.A. Care’s mission is to provide access to quality healthcare for Los Angeles County’s vulnerable and low-income residents to support the safety net required to achieve that purpose.
L.A. Care’s vision is a healthy community in which all have access to the health care they need.
Organizational Values:
- Accountable and responsive to the communities we serve and focus on making a difference.
- Reflects a commitment to cultural diversity and the knowledge necessary to serve our members with respect and competence.
- Driven by continuous improvement and innovation and aims for excellence and integrity.
- Demonstrates L.A. Care’s leadership by active engagement in community, statewide and national collaborations and initiatives aimed at improving the lives of vulnerable low-income individuals and families.
- Fosters and honors strong relationships with our health care providers and the safety net.
- Empowers our members by providing health care choices and education and encouraging their input as partners in improving their health.
- Puts people first, recognizing the centrality of our members and the staff who serve them.
Salary range: $135,136 (min.) - $175,676 (mid.) - $216,218 (max.) with annual bonus potential. The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
Benefits: Paid Time Off (PTO); tuition reimbursement; retirement plans; medical, dental & vision; wellness program; volunteer time off (VTO).
Contact:
Erica Eikelboom, Principal & Executive Search Consultant
Morgan Consulting Resources
erica@morganconsulting.com
POSITION DESCRIPTION
Company: L.A. Care Health Plan
Position: Director, Payment Integrity
Position Type: Non-Clinical
Position Level: Director
FLSA Designation: Exempt
Location: Los Angeles, CA (hybrid)
Job Summary
The Director, Payment Integrity defines the payment integrity operating model. As owner, is accountable for prevention, governance, analytics, risk reduction and sustained accuracy across all prepay and post pay activity. This position is responsible for designing, leading, and continuously improving the end-to-end Payment Integrity program. This position ensures the accuracy of provider payments, minimized inappropriate spend, and strengthens preventive and detective controls across all lines of business. The Director oversees clinical editing, data mining, cost-avoidance strategies, recovery operations, coordination of benefits (COB), third-party liability (TPL), and analytical review of billing and payment patterns.
The Director sustains a Payment Integrity operating model that prevents incorrect payments before they occur, improves the reliability of claims processing through strong upstream controls, identifies systemic issues contributing to payment errors, and drives operational, configuration, or provider-facing changes that improve accuracy over time. This leader partners closely with cross-functional teams and external vendors to ensure sustained, measurable impact on medical cost reduction, accuracy, audit readiness, and provider experience.
The Director leads a multi-functional team that includes internal data mining, clinical review, overpayment recovery, prospective pre-payment programs, and vendor management. The Director is responsible for building analytic and operational rigor, embedding standardized processes, and fostering a culture of accountability, operational consistency, and continuous improvement.
This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Develops strategic plans, drives change and influences critical business outcomes.
Essential Duties and Responsibilities
- Strengthens accuracy, prevents financial leakage, and ensures upstream and downstream controls operate as a cohesive system. Refines and enhances disciplined processes, improves the sustainability of controls, and leverages data to identify and mitigate risks before they impact members, providers, or financial performance. Through cross-functional collaboration, structured execution, and proactive problem-solving, enhances the organization’s ability to manage medical spend responsibly and ensure accurate, compliant payment outcomes.
- Develops and executes the Payment Integrity strategy, ensuring alignment with enterprise financial, operational, and regulatory priorities. Leads a comprehensive operating model that integrates pre-pay, post-pay, clinical editing, cost-avoidance, data mining, recovery operations, COB, and TPL functions. Designs and maintains governance frameworks, policies, workflows, and quality standards that strengthen preventive controls and reduce rework. Ensures consistent application of rules, benefit interpretation, pricing methodologies, and contract terms across all Payment Integrity activities.
- Oversees the development and implementation of pre-payment controls including clinical editing, code auditing, configuration recommendations, automated and algorithm-based edits, and pre-pay clinical and non-clinical reviews. Partners with cross functional teams to implement upstream changes that prevent recurring payment errors and reduce operational burden. Leads initiatives that increase automation, improve first-pass accuracy, and reduce the volume of post-pay recoveries.
- Oversees identification, validation, and recovery of overpayments across solicited and unsolicited sources, ensuring accuracy, transparency, and regulatory compliance. Leads recovery operations, including provider outreach, appeals support, repayment management, and reconciliation of recovery outcomes. Ensures post-pay findings feed into proactive improvements and preventive interventions, reducing future inappropriate payments.
- Directs internal data mining and analytical review functions to identify billing anomalies, emerging risk patterns, and cost avoidance opportunities. Partners with Analytics leaders to develop predictive models, dashboards, and trending tools that support smarter interventions and program scalability. Translates analytical insights into operational or system changes that reduce leakage and strengthen the accuracy of initial payment decisions.
- Oversees COB and TPL programs to ensure correct payer order, maximize cost avoidance, and support regulatory reporting requirements. Ensures timely, accurate, and complete responses to inquiries from DHCS or other regulatory bodies. Strengthens processes to reduce inappropriate payments that result from eligibility, coordination, or primary payer errors.
- Manages relationships with Payment Integrity vendors, ensuring contract compliance, performance against SLAs, timely implementation of new programs, and accurate financial reconciliation. Assesses vendor performance and identifies opportunities to optimize or expand program impact. Ensures vendor partners follow appropriate standards, quality controls, and documentation expectations.
- Ensures Payment Integrity processes meet all regulatory and contractual requirements across Medicaid, Medicare, Commercial, and Exchange lines of business. Leads or supports responses to audits, inquiries, corrective action plans, and regulatory reviews related to payment accuracy. Partners with QA to validate accuracy and consistency of Payment Integrity findings, recoveries, and interventions.
- Collaborates with Claims Administration, Configuration, Provider Network Management, EDI, Compliance, and Finance to address systemic issues and improve end-to-end payment outcomes. Advises leadership and internal partners on payment accuracy trends, root-cause drivers, provider impact, and mitigation strategies. Builds strong relationships with provider partners and communicates clearly on payment rules, system behaviors, and corrective actions.
- Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Develops, and manages budgets, utilizing resources effectively.
- Conducts strategic planning to utilize resources in order to meet current and future departmental and Enterprise-wide goals. Identifies and actualizes enhancements to support company vision.
- Develops and maintains relationships with key stakeholders. Leads discussions on policy operationalization and oversees key policy perspective sharing.
- Oversees succession planning to build technical expertise and operational consistency. Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.
- Performs other duties as assigned.
- Required: Bachelors Degree. In lieu of degree, equivalent education and/or experience may be considered.
- Preferred: Masters Degree; Business Administration or a related field preferred.
Required:
- At least 7 years of deep experience in Payment Integrity, Fraud/Waste/Abuse prevention, Claims Accuracy, Medical Cost Containment, and/or other Program Integrity functions.
- At least 5 years of experience leading, supervising and/or managing staff.
- Demonstrated experience in pre-pay and/or post-pay program oversight, cost-avoidance strategies, recovery operations, clinical editing, or data mining.
- Experience working with and interpreting provider contracts, benefit structures, pricing methodologies, and Medicaid/Medicare regulatory requirements.
- Experience developing and overseeing COB/TPL programs.
- Experience engaging with regulators, responding to audits, and overseeing and managing vendor partners.
- Experience implementing predictive analytics or algorithm-based Payment Integrity solutions.
- Strong interpersonal leadership skills and an ability to motivate and develop talent while driving accountability.
- Deep understanding of payment accuracy, claim rules, industry coding standards, reimbursement methodologies, and cost-containment strategies.
- Strong analytical, financial, risk-management and problem-solving skills.
- Ability to manage complex workflows, prioritize competing demands, and deliver results in high-volume environments.
- Ability to build strong teams that work effectively together and collaborate across the organization.
- Ability to establish and maintain effective working relationships with representatives at provider organizations and with internal stakeholders.
- Ability to interpret and apply complex operating instructions, state and federal regulations, and department/division procedures. Ability to understand, apply, and communicate rules, regulations and guidelines to others.
- Excellent written and verbal communication skills; speaks clearly and persuasively in positive or negative situations.
- Proficiency with Microsoft Office and data/reporting tools.
- Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.
- Demonstrated ability to make sound and timely decisions.
- Demonstrated ability to adapt to changing situations and adjust strategies accordingly.
- Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.
- Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment.
- Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.
Light: (Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly. Requires walking, standing to a significant degree, dexterity of hands and fingers to operate a variety of standard office equipment. Requires sitting most of the time, but entails pushing and/or pulling of arm or leg controls. The job may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.)
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