Strategic Payment Integrity Program Manager

Molina Healthcare; United States; On-site; USD 85,000 - 120,000; Full time

Job summary

Molina Healthcare in the United States seeks a senior Health Plan Payment Integrity Business Analyst to oversee PI recovery processes, CMS and state compliance, and data-driven optimization of pre-pay edits and overpayments.

You will collaborate with the PI team and finance partners to improve claim payment accuracy, manage SAIs, and drive cost-containment outcomes while communicating effectively with leadership and providers.

Qualifications

• 5+ years of business analyst experience in a managed care organization (MCO) and 3+ years in Medicaid/Medicare.
• Experience owning operational projects in provider reimbursement and claims payment integrity.
• Strong knowledge of CPT, ICD, HCPCS, Revenue Codes, and Medicaid payment rules.
• Proficient data analysis and ability to inform business decisions.
• Excellent written and verbal communication and cross-functional ownership.

Responsibilities

• Own scorable action items (SAIs) and ensure CMS/state requirements for pre-pay edits and overpayment recovery.
• Lead efforts to improve claim payment accuracy, referrals, and financial performance.
• Collaborate with operational teams, finance, and compliance to address issues and resolve risks.
• Provide recommendations to health plan leadership to support short- and long-term goals.
• Coordinate with network teams to communicate recovery projects and respond to provider inquiries.

Skills

Business analysis

Regulatory knowledge

Data analysis

Stakeholder management

Communication skills

Excel (Advanced)

Education

Bachelor's degree in health administration or related field

CBAP or CCS certification

Tools

MS Office Suite

Job description

Molina Healthcare in the United States seeks a senior Health Plan Payment Integrity Business Analyst to oversee PI recovery processes, CMS and state compliance, and data-driven optimization of pre-pay edits and overpayments.

You will collaborate with the PI team and finance partners to improve claim payment accuracy, manage SAIs, and drive cost-containment outcomes while communicating effectively with leadership and providers.