paylocity

Director of Payment Integrity Operations

ClaimInsight

Remote, USA

Full-time

Senior · 10+ years experience

Remote

Discovered 2 weeks ago

SQLPower BITableauAzure Data PlatformSnowflakeDatabricks

Apply

Full Job Posting

Key Responsibilities

Strategic Leadership
Establish scalable processes for data mining, opportunity identification, and
inventory generation.
Drive continuous improvement initiatives to increase claim opportunity yield,
accuracy, recovery rates, and operational efficiency.
Partner with executive leadership to define growth objectives, operational KPIs, and
client value metrics.
Identify emerging market opportunities and analytic methodologies to enhance
ClaimInsight capabilities.
Data Mining & Analytics Operations
Oversee all data mining activities associated with claims and payment integrity
programs.
Direct the development and optimization of algorithms, business rules, and data
models that identify:
Overpayments
Duplicate payments
Coordination of Benefits (COB) opportunities
Subrogation opportunities
Fraud, Waste, and Abuse (FWA) indicators
Eligibility discrepancies
Billing and coding anomalies
Contract compliance opportunities
Retrospective recovery opportunities
Ensure mining strategies consistently generate high-quality inventories that meet
client and operational performance expectations.
Manage prioritization of opportunities based on recoverability, financial impact, and
client objectives.
Operational Excellence
Establish performance standards and quality assurance processes across all
mining operations.
Monitor inventory generation, throughput, aging, and financial yield.
Develop operational dashboards and executive reporting to measure:
Opportunity identification rates
Recovery conversion rates
Revenue impact
Client ROI
Team productivity
Quality metrics
Implement workflow optimization initiatives that reduce cycle times and improve
scalability.
Cross-Functional Collaboration
Partner with Product Management to translate client and market requirements into
operational capabilities.
Work closely with Engineering and Data Science teams to enhance data ingestion,
automation, machine learning capabilities, and reporting functionality.
Collaborate with Recovery Operations leaders to ensure smooth intake and
resolution of identified opportunities.
Support Client Success teams with analytics, reporting, and performance reviews.
Team Leadership
Lead, mentor, and develop a high-performing team of managers, analysts, and
operational specialists.
Build workforce planning models aligned with business growth objectives.
Foster a culture of accountability, innovation, collaboration, and continuous
improvement.
Create career development pathways and succession planning strategies for key
operational roles.
Compliance & Data Governance
Ensure adherence to HIPAA, PHI security requirements, and organizational data
governance policies.
Maintain high standards for data quality, audit readiness, and regulatory
compliance.
Partner with compliance and legal teams to ensure mining methodologies align with
contractual and regulatory requirements.
Requirements
Bachelor's degree in Data Analytics, Healthcare Administration, Business,
Information Systems, Computer Science, Statistics, or related field.
10+ years of experience in healthcare claims analytics, payment integrity, recovery
auditing, healthcare operations, or data mining.
5+ years of leadership experience managing analytics or operational teams.
Strong knowledge of:
o Healthcare claims processing
o Medical coding systems (ICD, CPT, HCPCS)
o Coordination of Benefits
o Subrogation
o Payment integrity
o Retrospective recovery programs
Experience working with large healthcare claims datasets.
Advanced proficiency with SQL and data analytics platforms.
Demonstrated success leading operational transformation and process
optimization initiatives.
Preferred
Experience supporting health plans, TPAs, self-funded employers, or healthcare
payment integrity organizations.
Familiarity with predictive analytics and machine learning applications.
Experience with cloud-based data environments, including Azure, AWS, or Google
Cloud.
Lean Six Sigma certification or equivalent operational excellence training.
Technical Competencies
SQL
Power BI
Tableau
Azure Data Platform
Snowflake
Databricks
Healthcare claims systems
Data quality management
Statistical analysis
Predictive modeling
Workflow automation
Performance management analytics
Leadership Competencies
Strategic Thinking
Operational Excellence
Results Orientation
Executive Communication
Change Management
Client-Focused Leadership
Talent Development
Analytical Problem Solving
Cross-Functional Influence
Key Performance Indicators (KPIs)
The Data Mining Operations Director will be measured on:
Claims opportunity identification volume
Recovery inventory quality and accuracy
Financial recovery yield
Client ROI achievement
Inventory conversion rates
Operational efficiency improvements
Data quality scores
SLA adherence
Employee engagement and retention
Successful implementation of product enhancements
Why This Role Matters
The Data Mining Operations Director plays a critical role in maximizing the value of
ClaimInsight by transforming complex healthcare claims data into actionable recovery
opportunities. This position directly impacts client savings, revenue generation, operational
efficiency, and the continued growth and market leadership of the ClaimInsight platform.

Requirements

Bachelor's degree in Data Analytics, Healthcare Administration, Business,

Apply for this job in 1 click

Skip the repetitive application forms

Install the Base Career Chrome Extension and autofill job applications across major job boards with your profile.

Trusted by over 500,000 job seekers on Base Career

Start Free Today