Molina Healthcare of Kentucky is hiring a Program Manager, Health Plan Payment
Integrity (Claims & Recovery). This position is remote.
Highly Qualified Candidates Will Have the Following -
Managed care experience
Strong Medicaid experience, Medicare, Marketplace (Specifically Kentucky
Medicaid preferred, not required)
Claims processing and reimbursement knowledge, Claims processing knowledge on
the recovery side
Good working knowledge of CPT, HCPCS, ICD, and revenue codes
Payment Integrity, cost management, or similar claims experience
Strong analytical and problem solving skills
Ability to work independently and take ownership of assignments
Good communication skills
Comfortable working with multiple teams and different levels of leadership
Able to take a problem that may not have a clear answer and work through it
Essential Job Duties
Provides subject matter expertise for oversight, production, and resolution of
health plan payment integrity (PI) recovery concepts. Executes and monitors
health plan scoreable action items (SAIs) to ensure performance and quality
levels exist in PI Business products and processes. Establishes procedures and
techniques to achieve operational goals and executes tasks and projects to
ensure Centers for Medicare & Medicaid Services (CMS) and state regulatory
requirements are met for pre-pay edits and overpayment recovery. Manages
inventory and works in collaboration with PI team to ensure SAI targets are met.
Makes independent and informed decisions that contribute to health plan
strategy, and acts as a trusted voice in resolving complex business challenges
that impact cost-containment and regulatory compliance.
Business Leadership & Operational Ownership
• Independently owns and manages scorable action items (SAIs), including
assisting and executing projects and tasks to ensure Centers for Medicare and
Medicaid Services (CMS) and state regulatory requirements are met for pre-pay
edits, post-payment datamining, and overpayment recovery, to improve encounter
submissions, reduce general and administrative (G&A) expenses, and drive
positive operational and financial outcomes for all payment integrity (PI)
solutions.
• Independently leads efforts to improve claim payment accuracy, claim
referrals, adjustment analysis and financial performance.
• Collaborates with operational teams, enterprise stakeholders, and finance
partners to proactively identify issues and implement resolution strategies.
• Serves as a thought partner to health plan leadership, and provides
well-reasoned recommendations that support short- and long-term business goals.
• Partners with the network team to communicate recovery projects to ensure
provider relations is informed and able to respond to provider inquiries.
Strategic Business Analysis
• Uses a business lens to ensure accurate interpretation of provider claims
trends, payment integrity issues, and process gaps.
• Applies understanding of health care regulations, managed care claims
workflows, and provider reimbursement models to shape payment integrity related
recommendations and action plans.
• Translates strategic needs into clear requirements, workflows, and solutions
that drive measurable improvement.
• Partners with finance and compliance to develop business cases, and support
reporting that ties operational outcomes to financial targets.
Applied Analytical Support
• Uses data analysis tools/systems to support business analysis.
• Validates findings and test assumptions through data, and leads with
contextual knowledge of claims processing, provider contracts, and operational
realities.
• Creates succinct data summaries and visualizations that enable faster
leadership decision-making.
Required Qualifications
• At least 5 years of business analyst experience in a managed care organization
(MCO), and at least 3 years of experience in Medicaid and/or Medicare programs,
or equivalent combination of relevant education and experience.
• Proven experience owning operational projects from concept to execution,
especially in the areas of provider reimbursement and claims payment integrity.
• Strong working knowledge of managed care claims coding (Current Procedural
Terminology (CPT), International Classification of Diseases (ICD), Healthcare
Common Procedure Coding System (HCPCS), Revenue Codes), and federal/state
Medicaid payment rules.
• Strong data analysis/queries experience, and ability to analyze data to inform
business decisions.
• Strong business judgment, cross-functional coordination, and ownership of
high-value deliverables.
• Demonstrated ability to work independently and apply business judgment in a
highly regulated, cross-functional environment.
• Strong written and verbal communication skills, including ability to
synthesize complex information.
• Microsoft Office suite (including advanced Excel), and applicable software
program(s) proficiency.
Preferred Qualifications
• Experience with Medicare, Medicaid, and/or Marketplace lines of business.
• Certified Business Analysis Professional (CBAP) or Certified Coding Specialist
(CCS) certification.
• Project management experience.
• Familiarity with Medicaid-specific scorable action items (SAIs), operational
cost-management efforts, payment integrity (PI) programs, and
regulatory/compliance adherence.
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