Senior Director of Payment Integrity

The Senior Director, Payment Integrity leads the enterprise function responsible for ensuring claims are paid accurately, appropriately, and in accordance with plan benefits, provider contracts, reimbursement policies, clinical guidelines, and regulatory requirements. This role is accountable for developing and executing strategies that prevent, detect, correct, and recover improper payments while reducing financial leakage, supporting cost containment, and improving operational quality. This leader oversees end-to-end payment integrity capabilities, including pre-payment accuracy, post-payment audit and recovery, clinical and coding review, reimbursement and payment policy, fraud, waste and abuse support, provider billing trend analysis, and payment integrity analytics. The role partners closely with Claims, Clinical, Provider Network, Finance, Compliance, Legal, Technology, Data Analytics, and external vendors to strengthen payment controls, improve claims administration, and support transparent provider and member experiences.

• Develop and execute the enterprise Payment Integrity strategy, roadmap, and operating model to improve claims payment accuracy, reduce financial leakage and address risks related to errors, waste, abuse, fraud, policy gaps, reimbursement variation, and operational defects.
• Provide end-to-end strategic oversight of Payment integrity programs, including pre-payment prevention, post-payment recovery, clinical review, data mining, coding validation, reimbursement policy, provider education, analytics-driven monitoring, and continuous program optimization.
• Serve as an enterprise subject matter expert on payment integrity, reimbursement policy, claims accuracy, dental policy alignment, provider billing behavior, emerging payment risks, regulatory trends, and financial risk mitigation.
• Lead cross-functional planning and decision-making with Claims, Clinical, Dental Policy, Provider Network, Finance, Legal, Compliance, Technology, Operations and Analytics to align Payment Integrity priorities with enterprise goals and business performance targets.
• Oversee payment integrity operations across data mining, clinical record review, coding validation, claims editing, medical necessity review, pre-payment review, post-payment audit, and overpayment recovery, ensuring consistent, evidence-based, well-documented claim decisions.
• Partner with Dental Policy, Clinical, Network, Legal, Compliance, Claims, and analytics teams to translate policy and contract requirements into operationally sound payment rules, audit criteria and fraud, waste and abuse detection activities.
• Lead the use of advanced analytics, informatics, dashboards, and reporting to identify payment trends, provider outliers, claim anomalies, reimbursement variations, recovery opportunities, policy gaps, root causes of payment defects and strategic investment priorities.
• Establish, monitor, and report on key performance indicators, including payment accuracy, savings, recoveries, avoidance, audit yields, claim edit performance, overturn rates, provider disputes, turnaround times, vendor results, policy effectiveness, and operational quality.
• Ensure payment integrity programs comply with applicable federal and state regulations, accreditations standards, Corporate policies, contractual requirements, HIPAA, and payer compliance obligations while balancing cost containment, transparency, provider relationships, and member experience.
• Hire, coach develop, and retain high-performing leaders and subject matter experts across payment integrity, clinical review, analytics, payment policy, audit, and recovery operations.

• 12+ years w/Bachelor’s degree; 3+ years management 
• Additional experience may be accepted in lieu of education or degree
• 10+ years of progressive experience in a health plan, managed care organization, payer, TPA, or healthcare payment integrity environment. 
• 12+ years of leadership experience managing teams, programs, vendors, or enterprise-level initiatives.
• Strong experience in payment integrity, claims operations, reimbursement policy, clinical review, fraud, waste and abuse, post-payment recovery, pre-payment editing, data mining, or audit operations.
• Experience leading enterprise initiatives to prevent, detect, and recover improper claim payments. 
• Experience partnering with Claims, Clinical, Compliance, Legal, Finance, Provider Network, Technology, Data Analytics, and vendor organizations. 
• Strong executive presence, communication skills, stakeholder management, financial acumen, and change leadership capability. 
• Ability to travel up to 25%-30% of work time. Position may also be required to work in office as needed.
• Deep understanding of health plan claims administration, benefit interpretation, provider contracts, reimbursement methodologies, claims editing, medical policy, coding, billing practices, and payment rules.
• Demonstrated ability to use analytics, informatics, reporting, and KPIs to identify trends, manage performance, validate savings, and drive operational improvement.
• Strong executive presence, communication skills, stakeholder management, financial acumen, and change leadership capability.

Base Pay Information
The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental’s assessment of the candidate’s knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity. 
Pay Grade 26. $161,257-$372,629K