Health Plan Payment Integrity Program Manager

Socket.dev; United States; On-site; USD 90,000 - 130,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare is seeking a senior Business Analyst to oversee health plan payment integrity recovery concepts and drive operational excellence. The role focuses on scorable action items, CMS/regulatory compliance, and data-driven improvements to encounter submissions and G&A costs.

You will partner with network and finance teams to deliver measurable results. The ideal candidate has extensive experience in Medicaid/Medicare programs, strong analytical skills, and a track record of

Qualifications

• 5+ years of business analyst experience in managed care (MCO) organizations.
• 3+ years in Medicaid and/or Medicare programs or equivalent.
• Experience owning operational projects in provider reimbursement and claims payment integrity.
• Strong data analysis/queries experience to inform decisions.
• Proven ability to work independently in a highly regulated environment.

Responsibilities

• Own scorable action items (SAIs) and ensure CMS/state regulatory compliance for pre-pay edits and overpayment recovery.
• Lead efforts to improve claim payment accuracy and financial performance.
• Collaborate with operational teams, enterprise stakeholders, and finance partners to address issues and implement resolutions.
• Provide recommendations to health plan leadership to support short- and long-term goals.
• Communicate recovery projects with network teams to keep provider relations informed.

Skills

Business analysis

Data analysis/SQL queries

Advanced Excel

Cross-functional collaboration

Regulatory knowledge

Tools

Excel

Office suite

Job description

Molina Healthcare is seeking a senior Business Analyst to oversee health plan payment integrity recovery concepts and drive operational excellence. The role focuses on scorable action items, CMS/regulatory compliance, and data-driven improvements to encounter submissions and G&A costs.

You will partner with network and finance teams to deliver measurable results. The ideal candidate has extensive experience in Medicaid/Medicare programs, strong analytical skills, and a track record of