Program Manager, Health Plan Payment Integrity (MI)

Molina Healthcare•Detroit, MI

5h•$73,102 - $142,549

About The Position

The Program Manager, Health Plan Payment Integrity provides subject matter expertise in oversight, production, and resolution of health plan payment integrity recovery concepts. The role executes and monitors health plan scoreable action items (SAIs) to support performance and quality in payment integrity products and processes. It establishes procedures and techniques to meet operational goals and carries out tasks and projects to support CMS and state regulatory requirements for pre-pay edits and overpayment recovery. The position manages inventory, works with the payment integrity team to meet SAI targets, makes independent decisions that contribute to health plan strategy, and helps resolve complex cost-containment and regulatory-compliance challenges. The role owns and manages SAIs and operational projects related to pre-pay edits, post-payment data mining, overpayment recovery, encounter submissions, administrative expenses, and payment integrity outcomes. It leads work to improve claim payment accuracy, referrals, adjustment analysis, and financial performance; collaborates with operational teams, enterprise stakeholders, finance partners, and network teams; and advises health plan leadership with recommendations supporting business goals. It analyzes provider claims trends, payment integrity issues, and process gaps, applying knowledge of health care regulations, managed care claims workflows, and provider reimbursement models to develop requirements, workflows, and solutions. It also uses data analysis tools to validate findings, test assumptions, and produce summaries and visualizations for leadership decision-making. The employee must reside in Michigan.

Requirements

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 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/state Medicaid payment rules.
Strong data analysis and query experience, with 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.
Must reside in Michigan.

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 (PI) programs, and regulatory/compliance adherence.

Responsibilities

Own and manage scoreable action items (SAIs), including projects and tasks that support CMS and state regulatory requirements for pre-pay edits, post-payment data mining, and overpayment recovery.
Improve encounter submissions, reduce general and administrative expenses, and drive positive operational and financial outcomes for payment integrity solutions.
Lead efforts to improve claim payment accuracy, claim referrals, adjustment analysis, and financial performance.
Collaborate with operational teams, enterprise stakeholders, and finance partners to identify issues and implement resolution strategies.
Advise health plan leadership and provide recommendations that support short- and long-term business goals.
Partner with the network team to communicate recovery projects and help provider relations respond to provider inquiries.
Interpret provider claims trends, payment integrity issues, and process gaps using business context.
Apply knowledge of health care regulations, managed care claims workflows, and provider reimbursement models to develop recommendations and action plans.
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 operational outcomes and financial targets.
Use data analysis tools and systems to support business analysis; validate findings and test assumptions using data and contextual knowledge.
Create concise data summaries and visualizations to support leadership decision-making.
Manage inventory and work with the payment integrity team to meet SAI targets.