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Director, Provider Resolution & Recovery

Date: May 27, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5141 


Position Summary/Position


Under the direction of the Senior Director of Financial Compliance, the Director of Provider Claims Resolution & Recovery is responsible for directing post payment claims activities, including Provider Dispute Resolution, Delegated Provider appeals, Provider Call Center tasking and Overpayment Recoveries. 

Major Functions (Duties and Responsibilities)


1. Monitor the Provider claim payment dispute process to ensure disputes are acknowledged, evaluated, and resolved within regulatory timeframes.
2. Ensure the timely review and resolution of claim inquiries tasked by the Provider Call Center.
3. Oversee the Provider Appeals process relating to an IPA’s claim payment decision and the 7-day letter Capitation deduction process.
4. Responsible for regulatory-based appeal correspondence, including developing new letters, revisions, and discontinuing usage.
5. Oversee post-payment adjustments including refund posting, payment offsets, payment reversals, interest, and penalties.
6. Monitor Overpayment Recoveries to ensure resolution within regulatory and contractual timeframes. 
7. Ensure provider refund and retractions are researched and resolved according to IEHP contracts and policies. 
8. Communicate payment errors to internal partners to ensure the accurate payment and billing of claims.  
9. Develop a process to bring Credit Balance Recoveries in-house.
10. Encourage and facilitate Process Improvement activities to improve operational processes and procedures.
11. Participate, practice, and promote the IEHP Mission, Vision and Values, LEAN principles/practices and Strategic Priorities to all IEHP Team Members, building effective Team Member engagement and enterprise-wide collaboration.
12. Provide coaching and guidance to the Management Team to ensure we promote collaboration and empowerment for our Team Members.

Supervisory Responsibilities

Leader: Administers Hires, Terminations, and Performance Reviews

Experience Qualifications


Seven (7) years of experience leading, managing and motivating teams in a managed care environment. Five (5) years of experience overseeing Medi-Cal and Medicare claims auditing required.

Preferred Experience


Five (5) years of experience with Lean process improvement principals preferred.

Education Qualifications


Bachelor’s degree in Accounting, Finance, Healthcare Administration, or other related field from an accredited institution required.

Preferred Education


Master’s degree in Business Administration, Accounting, Finance, Public Health, or related field from an accredited institution preferred.

Professional Certification

Professional Licenses

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


Must have a strong knowledge of the principles and practices of managed care as well as a solid understanding of the DMHC, DHCS and CMS rules and regulations governing claims adjudication practices and procedures. Analytical skills with emphasis on claims auditing, financial recovery, and problem solving.

Skills Requirement


Strong leadership, sound decision-making and strong organizational skills. Excellent oral and written communication skills.

Abilities Requirement


Ability to build successful relationships across the organization.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


Sedentary work in an office environment.

Physical Requirements

Keyboarding: Traditional - FREQUENTLY
Keyboarding: Other - FREQUENTLY
Use of computer mouse - FREQUENTLY
Hearing: One-on-One - FREQUENTLY
Hearing: In a group - FREQUENTLY
Hearing: Over the Telephone/Cell Phone - FREQUENTLY
Hearing: Conference Speakers/Video Calls/Radio Calls - FREQUENTLY
Communicate: Information/ideas verbally - FREQUENTLY
Alternate Sit/Stand or Walk at Will - FREQUENTLY
Turning/rotation of wrist or hand - FREQUENTLY
Near Visual Acuity - FREQUENTLY
Perform complex and varied tasks - FREQUENTLY
Develop and maintain positive work relationships - CONSTANTLY
Regular contacts: co-workers, supervisor - FREQUENTLY
Decision-making - FREQUENTLY
Lead/Influence Others - FREQUENTLY
Work review - FREQUENTLY
Rapid Pace of work - FREQUENTLY
Control of work pace - FREQUENTLY
Problem Solving - FREQUENTLY
Understand and follow direction - FREQUENTLY
Regular and reliable attendance - CONSTANTLY


Starting Salary: $144,976.00  - $184,849.60  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles