Program Manager, Health Plan Payment Integrity (MI)

JOB DESCRIPTION

***Employee for this role must reside in Michigan***

Job Summary

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.

Essential Job Duties

• Business Leadership & Operational Ownership

• Independently owns and manages scorable action items (SAIs), including assisting and executing projects and tasks to ensure Centers for Medicare and Medicaid Services (CMS) and state regulatory requirements are met for pre-pay edits, post-payment datamining, and overpayment recovery, to improve encounter submissions, reduce general and administrative (G&A) expenses, and drive positive operational and financial outcomes for all payment integrity (PI) solutions.

• 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.

Required 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 (Current Procedural Terminology (CPT), International Classification of Diseases (ICD), Healthcare Common Procedure Coding System (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.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V