Program Manager, Health Plan Payment Integrity (Claims & Recovery) Remote

Molina Healthcare•United States,

3d•$59,810 - $129,589•Remote

About The Position

Molina Healthcare of Kentucky is hiring a remote Program Manager, Health Plan Payment Integrity (Claims & Recovery). The position provides subject matter expertise and operational oversight for health plan payment integrity recovery concepts, including production and resolution. It monitors scoreable action items (SAIs) and supports performance and quality across payment integrity products and processes. The role establishes procedures and techniques for operational goals and executes projects to meet CMS and state regulatory requirements for pre-pay edits, post-payment data mining, and overpayment recovery. The Program Manager manages inventory and collaborates with payment integrity teams to achieve SAI targets. The role independently makes informed decisions that support health plan strategy and helps resolve complex challenges affecting cost containment and regulatory compliance. It leads improvements in claim payment accuracy, referrals, adjustment analysis, and financial performance; works with operational, enterprise, finance, network, and provider-relations stakeholders; and provides recommendations to health plan leadership. The position analyzes provider claims trends, payment integrity issues, process gaps, regulations, managed-care claims workflows, and reimbursement models to develop recommendations, requirements, workflows, and solutions. It also uses data analysis tools to validate findings, test assumptions, create concise summaries and visualizations, and support reporting that connects operational outcomes with financial targets.

Requirements

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

Nice To Haves

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 scoreable action items (SAIs), operational cost-management efforts, payment integrity programs, and regulatory and compliance adherence.
Managed care experience and strong Medicaid experience; Kentucky Medicaid experience is preferred but not required.
Knowledge of claims processing and reimbursement, including claims recovery.
Strong analytical and problem-solving skills, ability to work independently and take ownership, good communication skills, comfort working with multiple teams and leadership levels, and ability to work through problems without clear answers.

Responsibilities

Own and manage scoreable action items (SAIs), including projects and tasks supporting CMS and state requirements for pre-pay edits, post-payment data mining, and overpayment recovery.
Improve encounter submissions, reduce general and administrative expenses, and support positive operational and financial outcomes for payment integrity solutions.
Lead efforts to improve claim payment accuracy, claim referrals, adjustment analysis, and financial performance.
Manage payment integrity inventory and collaborate with the payment integrity team to meet SAI targets.
Collaborate with operational teams, enterprise stakeholders, and finance partners to identify issues and implement resolution strategies.
Advise health plan leadership and provide recommendations supporting short- and long-term business goals.
Coordinate with the network team on recovery projects so provider relations can respond to provider inquiries.
Analyze provider claims trends, payment integrity issues, process gaps, healthcare regulations, claims workflows, and provider reimbursement models.
Translate strategic needs into requirements, workflows, and solutions that drive measurable improvement.
Partner with finance and compliance to develop business cases and support reporting tied to financial targets.
Use data analysis tools to validate findings, test assumptions, and create summaries and visualizations for leadership decision-making.