[Hiring] Program Manager, Health Plan Payment Integrity @Molina Healthcare

Role Description

Molina Healthcare of Kentucky is hiring a Program Manager, Health Plan Payment Integrity (Claims & Recovery). This position is remote.

Highly Qualified Candidates Will Have the Following:

• Managed care experience
• Strong Medicaid experience, Medicare, Marketplace (Specifically Kentucky Medicaid preferred, not required)
• Claims processing and reimbursement knowledge, Claims processing knowledge on the recovery side
• Good working knowledge of CPT, HCPCS, ICD, and revenue codes
• Payment Integrity, cost management, or similar claims experience
• Strong analytical and problem solving skills
• Ability to work independently and take ownership of assignments
• Good communication skills
• Comfortable working with multiple teams and different levels of leadership
• Able to take a problem that may not have a clear answer and work through it

Essential Job Duties

• Provides subject matter expertise for oversight, production, and resolution of health plan payment integrity (PI) recovery concepts.
• Executes and monitors health plan scoreable action items (SAIs) to ensure performance and quality levels exist in PI Business products and processes.
• Establishes procedures and techniques to achieve operational goals and executes tasks and projects to ensure Centers for Medicare & Medicaid Services (CMS) and state regulatory requirements are met for pre-pay edits and overpayment recovery.
• Manages inventory and works in collaboration with PI team to ensure SAI targets are met.
• Makes independent and informed decisions that contribute to health plan strategy, and acts as a trusted voice in resolving complex business challenges that impact cost-containment and regulatory compliance.

Business Leadership & Operational Ownership

• Independently owns and manages scorable action items (SAIs), including assisting and executing projects and tasks to ensure CMS and state regulatory requirements are met for pre-pay edits, post-payment datamining, and overpayment recovery.
• Independently leads efforts to improve claim payment accuracy, claim referrals, adjustment analysis and financial performance.
• Collaborates with operational teams, enterprise stakeholders, and finance partners to proactively identify issues and implement resolution strategies.
• Serves as a thought partner to health plan leadership, and provides well-reasoned recommendations that support short- and long-term business goals.
• Partners with the network team to communicate recovery projects to ensure provider relations is informed and able to respond to provider inquiries.

Strategic Business Analysis

• Uses a business lens to ensure accurate interpretation of provider claims trends, payment integrity issues, and process gaps.
• Applies understanding of health care regulations, managed care claims workflows, and provider reimbursement models to shape payment integrity related recommendations and action plans.
• Translates strategic needs into clear requirements, workflows, and solutions that drive measurable improvement.
• Partners with finance and compliance to develop business cases, and support reporting that ties operational outcomes to financial targets.

Applied Analytical Support

• Uses data analysis tools/systems to support business analysis.
• Validates findings and test assumptions through data, and leads with contextual knowledge of claims processing, provider contracts, and operational realities.
• Creates succinct data summaries and visualizations that enable faster leadership decision-making.

Qualifications

• At least 5 years of business analyst experience in a managed care organization (MCO), and at least 3 years of experience in Medicaid and/or Medicare programs, or equivalent combination of relevant education and experience.
• Proven experience owning operational projects from concept to execution, especially in the areas of provider reimbursement and claims payment integrity.
• Strong working knowledge of managed care claims coding (CPT, ICD, HCPCS, Revenue Codes), and federal/state Medicaid payment rules.
• Strong data analysis/queries experience, and ability to analyze data to inform business decisions.
• Strong business judgment, cross-functional coordination, and ownership of high-value deliverables.
• Demonstrated ability to work independently and apply business judgment in a highly regulated, cross-functional environment.
• Strong written and verbal communication skills, including ability to synthesize complex information.
• Microsoft Office suite (including advanced Excel), and applicable software program(s) proficiency.

Preferred Qualifications

• Experience with Medicare, Medicaid, and/or Marketplace lines of business.
• Certified Business Analysis Professional (CBAP) or Certified Coding Specialist (CCS) certification.
• Project management experience.
• Familiarity with Medicaid-specific scorable action items (SAIs), operational cost-management efforts, payment integrity (PI) programs, and regulatory/compliance adherence.

Benefits

• Molina Healthcare offers a competitive benefits and compensation package.

Company Description

• Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.