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

Molina Healthcare•Long Beach, CA

3d•Remote

About The Position

Molina Healthcare of Kentucky is hiring a remote Program Manager, Health Plan Payment Integrity, focused on claims and recovery. The role provides subject matter expertise and operational ownership for health plan payment integrity recovery concepts, scoreable action items (SAIs), pre-payment edits, post-payment data mining, and overpayment recovery. It supports compliance with CMS and state requirements while improving claim payment accuracy, encounter submissions, cost containment, and financial performance. The Program Manager independently manages operational initiatives and projects, interprets claims trends and payment integrity issues, and recommends improvements grounded in managed care workflows, reimbursement models, provider contracts, and regulatory requirements. The role collaborates with operational teams, enterprise stakeholders, finance, compliance, network teams, and health plan leadership. It also uses data analysis to validate findings, explain complex issues, and provide concise summaries and visualizations for decision-making.

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, particularly 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, with the ability to analyze data to inform business decisions.
Strong business judgment, cross-functional coordination skills, 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; Kentucky Medicaid experience is preferred but not required.
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.

Responsibilities

Provide subject matter expertise for oversight, production, and resolution of health plan payment integrity recovery concepts.
Execute and monitor health plan scoreable action items (SAIs) to support performance and quality in payment integrity products and processes.
Establish procedures and techniques to achieve operational goals and ensure CMS and state regulatory requirements are met for pre-payment edits and overpayment recovery.
Manage inventory and collaborate with the payment integrity team to meet SAI targets.
Independently own and manage SAIs, projects, and tasks involving pre-payment 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.
Provide health plan leadership with 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.
Analyze provider claims trends, payment integrity issues, and process gaps.
Translate strategic needs into requirements, workflows, and solutions that produce measurable improvements.
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, validate findings and assumptions, and create concise data summaries and visualizations for leadership.
Make independent, informed decisions that support health plan strategy and resolve complex business challenges affecting cost containment and regulatory compliance.