Director, Payment Integrity (Pre-Pay Edits) - REMOTE

Molina Healthcare; Washington; À distance; USD 140 000 - 210 000; Plein temps

Résumé du poste

Molina Healthcare, Inc. seeks a senior leader to head payment integrity initiatives, overseeing multi-market operations and driving recovery efficiency. You will shape strategic roadmaps, govern program areas, and partner with executive teams on planning, rate setting, and compliance.

The role emphasizes governance, analytics, and automation, with a focus on building organizational capability and leadership succession within the Payment Integrity function.

Qualifications

• At least 8 years of experience supporting health care operations, including 5 years payment integrity/claims experience.
• 3+ years in management/leadership roles.
• Experience with managed care payor programs (Medicare/Medicaid) preferred.
• Ability to build positive working relationships with coworkers, members, providers and customers.
• Strong organizational and time-management skills with ability to handle multiple projects.
• Excellent verbal and written communication skills.
• Proficient in Microsoft Office and related software.

Responsabilités

• Develops and executes the strategic roadmap for payment integrity functions across markets.
• Oversight of program areas like COB, subrogation, data mining, pre-pay edits, and PI disputes.
• Leads enterprise projects driving financial improvement and operating transformation.
• Partners with executives to align payment integrity with planning, rate setting, and compliance.
• Sets departmental goals, KPIs, and reporting to measure outcomes.
• Provides SME on claims processing, configuration logic, audit readiness, and vendor governance.
• Represents Payment Integrity in governance meetings and regulatory discussions.
• Oversees vendor selection, contracting, and ROI management for recovery efficiency.
• Champions automation and data-driven decision making.
• Mentors leaders and develops succession pipelines.

Connaissances

Strategic planning

Leadership

Healthcare payer experience

Stakeholder relations

Time management

Communication

MS Office

Description du poste

Job Summary

Leads and directs team responsible for payment integrity activities including recovery operations. Responsible for performance, quality levels and establishing procedures and techniques that achieve optimal payment integrity operational standards and production targets.

Essential Job Duties

• Develops and executes the strategic roadmap for payment integrity functions, ensuring alignment with enterprise objectives and regulatory standards.
• Oversees multiple program areas (e.g., COB, subrogation, data mining, pre-pay edits, PI disputes) and ensures consistent governance, methodology, and performance management across markets.
• Leads enterprise projects and large-scale initiatives that drive financial improvement, cost containment, and operational transformation.
• Partners with executive leadership and shared services functions to integrate payment integrity objectives into corporate planning, rate setting, and compliance frameworks.
• Establishes departmental goals, KPIs, and performance reporting mechanisms that measure and communicate enterprise payment integrity outcomes.
• Provides subject matter expertise across claims processing, configuration logic, audit readiness, and vendor governance to ensure accuracy and scalability.
• Represents Payment Integrity at enterprise governance meetings, shared services councils, and external regulatory discussions.
• Oversees vendor selection, contracting, and ROI management to maximize recovery efficiency and ensure long-term value creation.
• Champions innovation through automation, advanced analytics, and data-driven decision-making.
• Mentors leaders and develops succession pipelines, building organizational capability and leadership readiness.

Required Qualifications

• At least 8 years of experience supporting health care operations, including 5 years payment integrity/claims experience, or equivalent combination of relevant education and experience.
• At least 3 years management/leadership experience.
• Managed care payor experience, preferably in Medicare/Medicaid government-sponsored programs.
• Ability to establish and maintain positive and effective work relationships with coworkers, members, providers and customers.
• Strong organizational and time-management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
• Excellent verbal and written communication skills.
• Microsoft Office suite and applicable software program(s) proficiency.

Preferred Qualifications

• Understanding of ICD-9/10CM, MS-, AP- and APR-DRG reimbursement.
• Electronic medical record (EMR) and medical record repository experience.

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