Senior Manager, Payment Integrity

Come Grow With UsAt Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person – health, health care, and social services and supports – are met. We are seeking collaborators, innovators, and those who are driven to be their very best.If you are looking for a career of purpose and are passionate about having an impact on society’s health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.About this role:Reasonable Accommodations StatementTo accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.ESSENTIAL FUNCTIONSJob Function & ResponsibilitiesLead and manage Payment Integrity operations, including pre-pay edits, post-pay audits, recoveries and payment validationTranslate PI strategy into operational execution with clear goals, KPIs, and accountabilityBuild, develop, and mentor staff; establish clear expectations and performance standardsServe as a subject matter expert and thought leader on payment integrity best practices within managed care environmentOversee pre-payment and post-payment review, including clinical and coding audits, fraud, waste and abuse prevention and retrospective analysisEnsure timely identification, validation and recovery of overpayments in accordance with state, federal and contractual requirementsPartner with Claims Operations and Configuration to enhance auto-adjudication accuracy and claims editing controlsMonitor PI inventory, cycle times, recovery rates and financial impactManage PI vendors including performance monitoring, issue escalation and contract complianceReview vendor findings, savings methodologies, and ROI to ensure accuracy and transparencyLead corrective action plans (CAPs) and continuous improvement initiatives related to PI findingsEnsure PI operations are compliant with DHCS, CMS and managed care regulations and Gold Coast Health Plans policiesSupports internal and external audits, including DHCS readiness reviews and financial auditsMaintain strong documentation, controls and audit trails for PI activitiesIdentify systemic payment risks and recommend corrective actionsCollaborate with Claims, Finance, Compliance, Provider Network, IT and Configuration teams to resolve root-cause issuesProvide PI insights to leadership to support decision-making, budgeting and risk mitigationSupport provider education and remediation efforts related to payment integrity findingsDevelop and maintain dashboards and reports on PI performance, recoveries, trends and risk areasPresent PI results, risks and opportunities to senior leadershipDrive data-driven decision-making and continuous operational improvementKnowledge of:Principles and practices of health care service delivery and managed care, Medi-Cal eligibility, and benefits. Medical billing/coding (CPT, HCPCS, ICD-9 and ICD-10); COB/TPL regulations and guidelines.Claims operations and supporting information systems; experience in developing and tracking performance metrics.Principles, practices, techniques, and theories of claims administration and customer service for a government agency serving a diverse social and ethnic population.State and federal regulations as they relate to Medi-Cal managed care and other related business and policies governing managed care issues.Perform such other duties as assigned.Enter responsibilities.MINIMUM QUALIFICATIONSEducation & Experience: Bachelor's Degree (four-year college or technical school): PreferredMinimum 6 years of experience in one or more of the following areas:Payment Integrity or Program IntegrityMedical cost containmentFraud, Waste, and Abuse (FWA)Data mining or claim accuracyRelated healthcare claims or analytics functionsDemonstrated experience leading teams, projects, initiatives, and cross‑functional groups.Experience working within Medicaid and Medicare managed care programs.Experience with pre‑pay and/or post‑pay review, edit development, recovery operations, or claim logic development.Ability to interpret provider contracts, payment methodologies, and managed care benefit structures.Experience conducting complex claim reviews, performing root‑cause analysis, and meeting regulatory turnaround requirements.Experience with Coordination of Benefits (COB) and Third‑Party Liability (TPL) claims in a managed care environment.Experience managing or collaborating with vendor‑managed Payment Integrity programs.Experience applying predictive analytics or algorithm‑based PI solutions.Equivalent In lieu of degree: 8 plus years of experience in professional-level experience in a claims processing department as a manager; Preferably in a Medi-Cal/Medicaid managed care planKNOWLEDGE, SKILLS & ABILITIES Preferred Qualifications: Working knowledge of:Medicaid and Medicare managed care regulationsPayment Integrity methodologies and industry best practicesClaims processing systems, benefit configuration, and provider reimbursement methodologiesAbility to:Analyze complex data sets and identify trends, anomalies, and root causesCommunicate effectively with internal teams, leadership, providers, and external vendorsLead cross‑functional initiatives and drive operational improvementsManage competing priorities and meet regulatory turnaround timesAdditional experience or related background in:Managed care operationsMedi‑Cal and Medicare programsLeadership or supervisory rolesHealthcare analytics, audit, or compliance functions Technology & Software Skills: Advanced computer skills in MS Office products.Certifications & Licenses: Possession of, or ability to obtain, a valid appropriate California driver’s license. Maintain a satisfactory driving recordCompetency StatementsManagement Skills - Ability to organize and direct oneself and effectively supervise others.Business Acumen - Ability to grasp and understand business concepts and issues.Decision Making - Ability to make critical decisions while following company procedures.Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.Interpersonal - Ability to get along well with a variety of personalities and individuals.Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.Time Management - Ability to utilize the available time to organize and complete work within given deadlines.Consensus Building - Ability to bring about group solidarity to achieve a goal.Relationship Building - Ability to effectively build relationships with customers and co-workers.Presentation Skills - Ability to effectively present information publicly.Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.Judgment - The ability to formulate a sound decision using the available information.Communication, Oral - Ability to communicate effectively with others using the spoken word. Communication, Written - Ability to communicate in writing clearly and concisely. Problem Solving - Ability to find a solution for or to deal proactively with work-related problems. The estimated pay range for the position is:$142,000.00 - $213,000.00The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.900

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