Senior Payment Integrity Program Development Specialist

Inland Empire Health Plans; Rancho Cucamonga (CA); On-site; USD 90,000 - 150,000; Full time

Benefits offered by this job

Competitive salary

Fitness center on-site

Medical Insurance with Dental and Vis

Life, short-term, and long-term(dis)

Career advancement opportunities

Wellness programs

Flexible Spending Account

CalPERS retirement

457(b) contribution match

Paid life insurance

Pet care insurance

Job summary

Inland Empire Health Plans (IEHP) seeks a Senior Payment Integrity Program Development Specialist to lead research, analysis, and development of initiatives that improve payment accuracy and regulatory compliance. You will evaluate cost trends, claims patterns, and industry developments, managing a backlog of audit concepts and vendor solutions.

You will collaborate with Clinical, Policy, and SIU teams to translate findings into actionable outcomes, and help enhance fraud, waste, and abuse

Qualifications

• Bachelor's degree in business, health administration, or a related field from an accredited institution is required.
• Experience with SQL or data mining and complex claims analytics is required.
• Minimum five (5) years of relevant experience.
• Certification in RHIA, RHIT, CCS, CPC, CIC or similar preferred.

Responsibilities

• Drive research, analysis, and development of Payment Integrity initiatives to strengthen accuracy and compliance.
• Evaluate medical cost trends, claims patterns, and industry developments to manage audit concepts and vendor solutions.
• Refine logic, document processes, and partner with Clinical, Policy, and SIU to implement findings.
• Assess pre- and post-payment audit programs to enhance FWA detection and cost avoidance.

Skills

Analytical thinking

Communication

Presentation skills

Education

Bachelor's degree in business or health administration

RHIA/RHIT/CCS/CPC/CIC cert preferred

Tools

SQL

MS Excel

Data mining

Job description

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to anauthentic experience!

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.

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

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!