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

Jobgether; United States; À distance; USD 69 000 - 135 000; Plein temps

Avantages offerts par ce poste

Remote work flexibility

Competitive compensation

Cross-functional collaboration

Résumé du poste

Jobgether is seeking a Program Manager, Health Plan Payment Integrity (Claims & Recovery) in the United States. This remote, full-time role leads payment integrity initiatives, oversees recovery programs, and works with claims, finance, compliance, and network teams to deliver compliant, data-driven solutions.

The ideal candidate has 5+ years in managed care analytics, Medicaid/Medicare experience, and strong data analysis skills.

Qualifications

• 5+ years as a business analyst in a managed care organization.
• 3+ years Medicaid/Medicare experience or equivalent.
• Experience managing operational projects from concept to execution.
• Strong knowledge of CPT, ICD, HCPCS, and revenue codes.
• Understanding of federal/state Medicaid payment regulations.
• Experience in payment integrity or related healthcare claims operations.
• Strong data analysis and querying ability.
• Excellent communication and cross-functional collaboration.

Responsabilités

• Lead health plan payment integrity initiatives and drive improvements.
• Manage SAIs and ensure targets are met.
• Oversee CMS/state regulatory pre/post-payment activities.
• Collaborate with claims, finance, compliance, and network teams.
• Translate complex challenges into actionable strategies.
• Prepare data summaries and visualizations for leadership.
• Develop business cases and reporting linking outcomes to financial targets.

Connaissances

Healthcare analytics

Stakeholder communication

Regulatory compliance

Data analysis

Project leadership

Outils

Excel

SQL

Data visualization

Description du poste

This position is listed on behalf of a partner company, which manages all applications and next steps. Our partner is looking for a Program Manager, Health Plan Payment Integrity (Claims & Recovery) based in the United States.

This is an opportunity for an experienced healthcare professional to lead payment integrity initiatives that improve claims accuracy, strengthen cost management, and support regulatory compliance across health plan operations. In this role, you will oversee recovery programs, manage key performance action items, and drive projects focused on pre-payment edits, post-payment analysis, and overpayment recovery. You will work closely with claims, finance, compliance, network, and operational teams to identify issues and deliver effective solutions. Combining managed care expertise with strong analytical and business judgment, you will translate complex challenges into actionable strategies and measurable results. This is a full-time remote position in a highly regulated, cross-functional environment.

Accountabilities

• Lead and manage health plan payment integrity initiatives, providing subject matter expertise across recovery concepts, operational processes, and business solutions.
• Own and execute scoreable action items (SAIs), ensuring performance targets, quality standards, and operational objectives are achieved.
• Oversee projects and activities that support CMS and state regulatory requirements for pre-payment edits, post-payment data mining, and overpayment recovery.
• Manage payment integrity inventory in collaboration with relevant teams to ensure recovery targets and deliverables are met.
• Drive improvements in claims payment accuracy, claim referrals, adjustment analysis, and financial performance.
• Identify payment integrity issues, claims trends, and process gaps, and develop effective strategies to address them.
• Collaborate with operational teams, enterprise stakeholders, finance, compliance, and network partners to resolve complex challenges and support business priorities.
• Provide strategic recommendations and serve as a trusted advisor to health plan leadership, contributing to both short- and long-term goals.
• Coordinate with network and provider relations teams to communicate recovery initiatives and ensure they are prepared to address provider questions.
• Apply knowledge of healthcare regulations, managed care claims workflows, provider contracts, and reimbursement models to develop actionable business requirements and solutions.
• Use data analysis tools and queries to validate findings, test assumptions, and assess operational performance.
• Prepare concise data summaries and visualizations that help leadership make informed decisions.
• Partner with finance and compliance teams to develop business cases and reporting that connect operational outcomes with financial targets.

Requirements

• At least 5 years of business analyst experience within a managed care organization (MCO), and at least 3 years of experience working with Medicaid and/or Medicare programs, or an equivalent combination of relevant education and experience.
• Demonstrated experience managing operational projects from initial concept through execution, particularly in provider reimbursement and claims payment integrity.
• Strong understanding of managed care claims processing, reimbursement, and coding systems, including CPT, ICD, HCPCS, and revenue codes.
• Knowledge of federal and state Medicaid payment regulations and requirements.
• Experience in payment integrity, cost management, claims recovery, or related healthcare claims operations.
• Strong data analysis and querying capabilities, with the ability to interpret findings and use data to support business decisions.
• Excellent analytical and problem-solving skills, including the ability to navigate complex or ambiguous challenges independently.
• Strong business judgment and a demonstrated ability to take ownership of high-value deliverables in a regulated, cross-functional environment.
• Excellent written and verbal communication skills, including the ability to synthesize complex information and present clear recommendations to different audiences.
• Ability to collaborate effectively with operational teams, enterprise stakeholders, and leadership at multiple levels.
• Proficiency in Microsoft Office, particularly advanced Excel, and other relevant business software.
• Preferred: Experience with Medicare, Medicaid, and/or Marketplace lines of business, with Kentucky Medicaid experience considered an advantage.
• Preferred: Certified Business Analysis Professional (CBAP) or Certified Coding Specialist (CCS) certification.
• Preferred: Project management experience and familiarity with Medicaid-specific SAIs, payment integrity programs, operational cost-management initiatives, and regulatory compliance.

Benefits

• Annual salary range of $69,447 to $135,421, with actual compensation varying according to geographic location, professional experience, education, and skill level.
• Full-time remote work arrangement.
• Competitive compensation and benefits package.
• Opportunity to contribute to initiatives that improve healthcare payment accuracy, operational efficiency, and financial performance.
• Collaborative work environment involving cross-functional teams and health plan leadership.