JOB DESCRIPTION

The Director of Payment Integrity owns the end-to-end Enterprise-level Payment Integrity (PI) strategy and activity across the organization. This role is expected to lead cross-functional teams in the planning, design, implementation, and ongoing maintenance of the framework, processes, tools, policies, and data sources that contribute to these emerging and critical Enterprise PI financial functions. The Director of Payment Integrity is responsible for managing all aspects of dental payment integrity, partnering with Claims leaders to ensure that dental claims are accurately and appropriately processed and paid in compliance with regulatory and contractual requirements. This role involves overseeing a team of payment integrity analysts and coordinating with internal stakeholders to identify, investigate, and resolve payment errors, fraudulent activity, and billing discrepancies.

RESPONSIBILITIES

• Directs operational payment integrity activities across the organization in support of all lines of business, including post- and pre-pay audit functions, payment recovery processes, COB, subrogation, dental record review, and fraud, waste and abuse clinical reviews in partnership with other divisions.
• Ensures payment integrity processes are in compliance with Federal and State regulatory and contractual requirements.
• Consolidates validated PI financial value data from various sources to enable reporting, trend analysis, benchmarking, and forecasting in support of executive-level decisions and customer acquisition and retention.
• Oversees the design, development, automation, and maintenance of dashboards that demonstrate PI value delivery across multiple dimensions for executives and current and prospective customers.
• Develops enterprise PI performance management program, including goals and Key Performance Indicators (KPI) based on performance trends, opportunity analyses, and market-based benchmarks.
• Oversees and coordinates the ongoing enterprise PI value management processes including financial reporting, financial process compliance, data integrity, and issue and risk management.
• Directs complex analysis of enterprise PI value from numerous internal and external data sources to understand trends, performance to goals and benchmarks, variances, and opportunities for financial and operational improvement.
• Designs, implements, and provides ongoing oversight of processes required to establish consistently reliable enterprise PI financial value forecasts. Serves as the owner of all methods and tools required to enable the enterprise PI financial value forecast model, and advocates and leads initiatives for forecast model improvement.
• Partners with Billing and Network, Oversight & Compliance (NOC) departments to identify trends in billing practices and potential fraud, waste, and abuse.
• Works collaboratively with internal stakeholders, such as Billing, Claims, and Contract Management teams to investigate and resolve payment discrepancies.

QUALIFICATIONS

• 12+ years w/Bachelor's degree; 3+ years management
• A minimum of 10 years of related work experience in various functions of payment integrity, such as claims editing, enrollment, coordination of benefits, overpayment identification, fraud, waste and abuse and health care subrogation/third party liability. This role requires past experience in managing resourcing/staffing, and having worked directly with the C-suite/VP level on a regular basis.
• Hands-on understanding and a tenured leadership foundation in claims processing, COB processing and benefits, with an understanding of claims fee schedule methodology.
• Knowledge of managed care and Medicare plan concepts, principles, practices, operations and requirements.
• Proven skill in project management, including the ability to track, prioritize, and drive multiple concurrent projects to success. Flexibility to adapt and manage assignments as they evolve and are replaced by other priorities in a dynamic environment.
• Excellent communicator in written and verbal form; ability to work well with executives, and to lead and influence across multiple levels and multiple functions of an organization.
• Entrepreneurial, with skill in navigating ambiguity and complexity.
• Financial prowess and ability to create budgets, models, etc.. This position is expected to utilize data and metrics to communicate needs with the ease of a business unit owner.
• Highest level of integrity and management of confidential information.
• Strong ability to influence and collaborate. Comfortable providing strategic advice to senior leadership.
• Must be able to travel as needed.

Licenses

• N/A (Not Applicable). n/a '

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. $133,300 - $260,000

ADDITIONAL INFORMATION

Rewards to make you smile! We don't just want to make our customers happy - we want to give our employees a reason to smile, too. Delta Dental's comprehensive benefits package includes:

• Generous paid time off plus 12 holidays and your birthday off!
• Low-cost premium medical insurance options
• 100% paid dental and vision insurance
• Generous 401(k) matching and flat contribution
• Social responsibility and volunteer opportunities, including 16 paid volunteer hours annually
• Employee LiveWell program, focusing on overall employee well-being
• Fertility and diabetes benefits
• Employee discount program: AT&T/Verizon, entertainment, travel, and more!
• Culture of learning: career development and tuition reimbursement
• Career growth: we love promoting from within

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

#LI-Remote

ABOUT THE TEAM

At Delta Dental, our success is only as strong as the people who execute it! We take enormous pride in being the nation's most recognized and widely-used provider of dental insurance - and we've come this far by living our core values of innovation, excellence, service and trust. Our vision is to motivate and empower every employee so that we're all inspired to take exceptional care of our customers, providers and ourselves. We believe in integrity, accountability, collaboration, and giving every employee equitable opportunity for their voice to be heard and development to be fostered.

If you're excited about the prospect of transforming the future of health care and growing in your career, join our smile revolution!

To see some of the smiling faces behind Delta Dental and to learn more about what our values and culture look like in action, connect with us on social media: Delta Dental Ins. on Facebook and Instagram, #LifeatDDins on Facebook and Instagram, Delta Dental Ins. on Twitter and Delta Dental Ins. on LinkedIn.

We are part of the Delta Dental Plans Association, a network of companies that provides dental coverage to 74 million people in the U.S. Delta Dental of California, Delta Dental of New York, Inc., Delta Dental of Pennsylvania and Delta Dental Insurance Company, together with our affiliate companies, form one of the nation's largest dental benefits delivery systems, covering 33 million enrollees. All of our companies are members, or affiliates of members, of the Delta Dental Plans Association, a network of 39 Delta Dental companies throughout the country.

Delta Dental is an equal opportunity employer. We are committed to building and maintaining a diverse and inclusive workplace for all employees. Applicants will not be discriminated against because of race, color, religion, creed, national origin, ancestry, citizenship status, sex (including pregnancy), sexual orientation, gender or identity expression, age, disability, marital status, medical status, veteran status or any other status protected under federal, state, or local law. In addition to federal law requirements, Delta Dental complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Unfortunately, our Delta Dental Enterprise is unable to hire individuals residing in Alaska, North Dakota, Nebraska, Hawaii, Oklahoma, Vermont, Maine, West Virginia, New Hampshire, Wyoming, Puerto Rico or other US Territories at this time.

Proof of eligibility to work in the United States must be provided if selected for hire.

Delta Dental* has enacted a COVID-19 vaccination policy to protect all employees and the communities we serve due to the ongoing impacts of the COVID-19 pandemic. Accordingly, we require all employees to be fully vaccinated for COVID-19. Are you able to comply with our policy of being fully vaccinated by your start date if an offer is made or have a medical or sincerely held religious exemption for receiving a COVID-19 vaccine? Failure to comply with our policy and submit proof of compliance or receive approval for a valid medical or sincerely held religious belief exemption prior to your start date will nullify any offer of employment extended to you.

• Delta Dental includes: Delta Dental of California, Delta Dental Insurance Company, Delta Dental of Pennsylvania, and Delta Dental of New York