Director of Payment Integrity Operations
The Data Mining Operations Director is responsible for leading the strategic, operational,
and analytical functions that power the ClaimInsight platform. This role oversees the
identification, acquisition, processing, validation, and optimization of healthcare claims,
payment integrity, and recovery opportunity data used to drive client outcomes and
product performance.
The Director will lead a multidisciplinary team of data analysts, data mining specialists,
operations managers, and quality professionals to ensure ClaimInsight delivers accurate,
actionable, and scalable insights that identify overpayments, billing anomalies, fraud,
waste, abuse, coordination of benefits opportunities, subrogation opportunities, and
retrospective recovery initiatives.
This leader serves as a critical bridge between Product Management, Clinical Operations,
Recovery Operations, Engineering, Data Science, and Client Success teams to maximize
value creation for health plan, employer, and third-party administrator (TPA) clients.
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.