Remote Health Plan Payment Integrity Lead

Molina Healthcare, Inc.; United States; A distancia; USD 69.000 - 135.000; Jornada completa

Descripción de la vacante

Molina Healthcare of Kentucky is seeking a Program Manager, Health Plan Payment Integrity (Claims & Recovery) to lead PI efforts remotely. You will oversee SAIs, ensure regulatory compliance, and collaborate with CMS/state teams to optimize pre-pay edits, post-payment datamining, and overpayment recovery.

The role emphasizes independent ownership, strong analytical skills, and effective communication across cross-functional teams to improve cost containment and provider outcomes.

Formación

• 5+ years of business analyst experience in a managed care organization (MCO).
• At least 3 years of Medicaid and/or Medicare program experience.
• Strong data analysis/queries experience to inform decisions.
• Solid CPT/HCPCS/ICD knowledge and Medicaid payment rules.

Responsabilidades

• Provide SME oversight for payment integrity recovery concepts and SAIs.
• Lead efforts to meet CMS and state pre-pay edits and overpayment recovery.
• Collaborate with PI teams to achieve SAI targets and cost containment.
• Partner with networks, finance, and compliance to drive improvements.

Conocimientos

Managed care

Medicaid experience

Medicare experience

Claims processing

Coding knowledge

Payment integrity

Analytical skills

Communication

Cross-functional collaboration

Independence

Descripción del empleo

Molina Healthcare of Kentucky is seeking a Program Manager, Health Plan Payment Integrity (Claims & Recovery) to lead PI efforts remotely. You will oversee SAIs, ensure regulatory compliance, and collaborate with CMS/state teams to optimize pre-pay edits, post-payment datamining, and overpayment recovery.

The role emphasizes independent ownership, strong analytical skills, and effective communication across cross-functional teams to improve cost containment and provider outcomes.