Director, Integrity

Overview

Salary Range: $ (Min.) - $ (Mid.) - $ (Max.)

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.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County s vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

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, over payment 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.

• 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…