Overview

Reporting to the Manager of Payment Integrity Program Development, the Senior Payment Integrity Program Development Specialist services 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.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Additional Benefits

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account - Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

Key Responsibilities

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

Qualifications

Education & 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.
• Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred

Key Qualifications

• 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

Start your journey towards a thriving future with IEHP and apply TODAY!

Work Model Location

This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA.)

Pay Range

USD $80,059.20 - USD $106,059.20 /Yr.