Senior Manager, Payment Integrity

Come Grow With Us At 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 Work Culture: GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work – Together. GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer). Core Values Integrity Accountability Collaboration Trust Respect Disclaimers Flexible work schedule is based on job duties, department, organization, or business need. Gold Coast Health Plan will not sponsor applicants for work visas. Reasonable Accommodations Statement To 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 Functions Build, lead and manage Payment Integrity operations, including pre-pay edits, post-pay audits, recoveries and payment validation. Translate PI strategy into operational execution with clear goals, KPIs, and accountability. Build, develop, and mentor staff; establish clear expectations and performance standards. Serve as a subject matter expert and thought leader on payment integrity best practices within managed care environment. Oversee pre-payment and post-payment review, including clinical and coding audits, fraud, waste and abuse prevention and retrospective analysis. Ensure timely identification, validation and recovery of overpayments in accordance with state, federal and contractual requirements. Partner with Claims Operations and Configuration to enhance auto-adjudication accuracy and claims editing controls. Monitor PI inventory, cycle times, recovery rates and financial impact. Manage PI vendors including performance monitoring, issue escalation and contract compliance. Review vendor findings, savings methodologies, and ROI to ensure accuracy and transparency. Lead corrective action plans (CAPs) and continuous improvement initiatives related to PI findings. Ensure PI operations are compliant with DHCS, CMS and managed care regulations and Gold Coast Health Plans policies. Support internal and external audits, including DHCS readiness reviews and financial audits. Maintain strong documentation, controls and audit trails for PI activities. Identify systemic payment risks and recommend corrective actions. Collaborate with Claims, Finance, Compliance, Provider Network, IT and Configuration teams to resolve root-cause issues. Provide PI insights to leadership to support decision-making, budgeting and risk mitigation. Support provider education and remediation efforts related to payment integrity findings. Develop and maintain dashboards and reports on PI performance, recoveries, trends and risk areas. Present PI results, risks and opportunities to senior leadership. Drive data-driven decision-making and continuous operational improvement. Knowledge 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. Minimum Qualifications Bachelor's Degree (four-year college or technical school): Preferred. Minimum 6 years of experience in one or more of the following areas: Payment Integrity or Program Integrity; Medical cost containment; Fraud, Waste, and Abuse; Data mining or claim accuracy; Related healthcare claims or analytics functions. Demonstrated 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 10–12+ progressively responsible, related experience preferably in a Medi-Cal/Medicaid managed care plan including 7+ years in management. 8 plus years of experience in professional-level experience in a claims processing department as a manager. Knowledge, Skills & Abilities (Preferred Qualifications) Working knowledge of Medicaid and Medicare managed care regulations; payment integrity methodologies and industry best practices; claims processing systems, benefit configuration, and provider reimbursement methodologies. Ability to: analyze complex data sets and identify trends, anomalies, and root causes; communicate effectively with internal teams, leadership, providers, and external vendors; lead cross functional initiatives and drive operational improvements; manage competing priorities and meet regulatory turnaround times. Additional experience or related background in managed care operations; Medi Cal and Medicare programs; leadership or supervisory roles; healthcare 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 record. Competency Statements Management 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. Estimated Pay Range $142,000.00 - $213,000.00 (California). #J-18808-Ljbffr Ventura County Medi-Cal Managed Care Commission