Director of Payment Integrity

HealthPartners is hiring a Director of Payment Integrity. The Director of Payment Integrity will lead the strategic development, implementation, and oversight of payment integrity programs across all lines of business, including Fully Insured Commercial, Self-Funded, Medicare Advantage, and Medicaid lines of business. This role is responsible for ensuring accurate claims payment, identifying and recovering inappropriate payments, and preventing future payment errors through data-driven insights, cross-functional collaboration, and vendor partnerships. The Director will play a critical role in safeguarding financial performance while promoting compliance, operational excellence, and member/provider satisfaction.

MINIMUM QUALIFICATIONS:

Education, Experience or Equivalent Combination:

Education: Bachelor's degree in Business Administration, Healthcare Administration, Finance, or a related field.

Experience: Minimum of 8 years of progressive experience in healthcare payment integrity, claims operations, or healthcare finance, with at least 3 years in a leadership or management role.

Equivalent Combination: An equivalent combination of education and experience may be considered in lieu of a degree.

Knowledge, Skills, and Abilities:

Strong understanding of health plan operations, claims processing, and payment integrity functions.

Working knowledge of regulatory requirements for Medicare Advantage, Medicaid, and Commercial lines of business.

Proven ability to lead cross-functional teams and manage complex projects.

Proficiency in data analysis and reporting tools (e.g., Excel, SQL, Tableau).

Excellent communication, negotiation, and stakeholder management skills.

Ability to work in a fast-paced, matrixed environment with competing priorities.

Strong interpersonal and collaborative skills to lead and influence teams at all levels of the organization.

Solid analytical, project and financial management skills.

Ability to offer creative, cost-effective alternatives and options to solve problems and meet customer needs.

Strong oral and written communications.

PREFERRED QUALIFICATIONS:

Education, Experience or Equivalent Combination:

Education: Master's degree in Healthcare Administration, Business, Public Health, or a related field.

Experience: 10+ years of experience in payment integrity or healthcare cost containment, with 5+ years in a senior leadership role overseeing multi-line health plan operations (Commercial, Self-Funded, Medicare Advantage, Medicaid).

Experience managing external vendors and third-party payment integrity solutions.

Licensure/ Registration/ Certification:

Preferred certifications:

AHFI (Accredited Health Care Fraud Investigator)

CHC (Certified in Healthcare Compliance)

CFE (Certified Fraud Examiner)

Six Sigma or Lean certification for process improvement

Knowledge, Skills, and Abilities:

Deep expertise in payment integrity strategies including pre-pay and post-pay audits, FWA detection, COB, and TPL.

Familiarity with CMS and state Medicaid audit protocols and compliance frameworks.

Advanced analytical and strategic thinking skills with the ability to translate data into actionable insights.

Experience with enterprise claims platforms and integration with payment integrity tools.

Demonstrated success in driving cost savings and operational improvements through innovation and collaboration.

ESSENTIAL DUTIES:

Strategic Leadership:

• Develop and execute a comprehensive payment integrity strategy aligned with organizational goals and regulatory requirements.
• Lead cross-functional initiatives to enhance claims accuracy, reduce waste, and improve cost containment.

Program Oversight:

• Manage end-to-end payment integrity operations including pre-pay and post-pay audits, fraud/waste/abuse detection, coordination of benefits, and third-party liability.
• Oversee vendor relationships and performance, ensuring accountability and ROI.

Analytics & Reporting:

• Leverage advanced analytics to identify trends, root causes, and opportunities for improvement.
• Develop and present executive-level reporting on savings, recoveries, and program impact.

Compliance & Quality:

• Ensure adherence to federal and state regulations, including CMS and Medicaid guidelines.
• Collaborate with Legal, Compliance, and SIU teams to mitigate risk and ensure audit readiness.

Team Development:

• Build and lead a high-performing team of analysts, auditors, and program managers.

Foster a culture of continuous improvement, innovation, and accountability.

LEADERSHIP RESPONSIBILITY:

Provides leadership for the Payment Integrity Office within the health plan operational area, with oversight of six functional areas highlighted below and complete accountability for these areas from a cost avoidance and cost savings perspective.

Key Areas of Responsibility Include:

SIU / Fraud, Waste & Abuse (FWA): Engage OIG and law enforcement. Triage all international claims. Implement DHS Payment Withholds. Monitor CMS Alerts. Assess overlaps across inpatient and other services. Support provider audits. Oversight of delegate FWA efforts.

Pre-Payment Integrity: Responsible for all pre-pay PI functions, Including: Claims Editing, Claims Coding, High $ Claims Review, COB Avoidance, Prospective Payment and Provider Advocacy.

Post-Payment Integrity: Responsible for all post-pay PI functions, Including: DRG and medical bill audit, Credit Balance Audit, Retrospective clinical reviews, COB Subrogation & Recovery services.

Payment Integrity Vendor Management: Monitor vendor performance against goals. Ensure compliance with contracts. Primary PI Engagement point of contact (PoC) with key partners and vendors supporting our solutions and systems within the Payment Integrity space.

Innovation (R&D): Payment & Reimbursement Policy ownership. Conducts research and development for new PI ideas. Identify and gather ideas from other sources (internally & externally). Assess use and enablement of advanced technologies (AI, gLLM, etc...)

COB & Subrogation: Responsible for recovering funds where other entity (e.g. workers comp, auto policy, etc...) should be primary payer. Intersection between legal & claims. Provide oversight for Subrogation Program Recoveries against associated costs of recoveries.