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.

• 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.