JOB DESCRIPTION Job Summary
Leads and manages 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
• Leads and manages day-to-day operations for assigned payment integrity
programs, ensuring accuracy, timeliness, and adherence to policies and
procedures.
• Hires, trains, and develops staff responsible for inventory management,
reporting, data integrity, and recovery performance.
• Implements and monitors quality assurance programs and performance metrics
to ensure recovery and cost avoidance targets are met.
• Collaborates with internal departments (Shared Services) to resolve system
or process issues impacting payment accuracy.
• Reviews and refines workflows and standard operating procedures to improve
efficiency, accuracy, and audit readiness.
• Facilitates meetings with vendors and internal partners to discuss
production performance, operational barriers, and process optimization
opportunities.
• Analyzes operational data to identify trends, evaluate recovery
effectiveness, and propose actionable improvements.
• Supports compliance with CMS and state regulations.
• Contributes to small- to mid-scale projects focused on process improvement,
automation, and data accuracy.
• Promotes a culture of accountability, continuous improvement, and
professional development within the team.
Required Qualifications
• At least 7 years of experience supporting health care operations, including 4
years payment integrity/claims experience, or equivalent combination of relevant
education and experience.
• At least 1 year management/leadership experience.
• 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.
• Strong verbal and written communication skills.
• Microsoft Office suite and applicable software program(s) proficiency.
Preferred Qualifications
• Managed care payor experience, preferably with Medicare/Medicaid
government-sponsored programs.
• Understanding of ICD-9/10CM, MS-, AP- and APR-DRG reimbursement.
• Electronic medical record (EMR) and medical record repository experience.
To all current Molina employees: If you are interested in applying for this
position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina
Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V