Molina Healthcare · 17 hours ago
Program Manager, Health Plan Payment Integrity (REMOTE - Connecticut Based Candidate Preferred)
United States
Full-time
Remote
Senior Level
5+ years expMolina Healthcare is seeking a Program Manager for Health Plan Payment Integrity to provide subject matter expertise in overseeing health plan payment integrity recovery concepts. The role involves executing and monitoring health plan scoreable action items to ensure compliance with regulatory requirements and improve operational outcomes.
Health CareHospitalMedical
Responsibilities
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
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
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
Qualification
Required
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
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
Benefits
Competitive benefits and compensation package
Company
Molina Healthcare
Molina Healthcare is a healthcare company that specializes in government-sponsored healthcare programs for families and individuals.
10001+ employees
H1B Sponsorship
Molina Healthcare has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (56)
2024 (45)
2023 (43)
2022 (31)
2021 (35)
2020 (55)
Funding
Current Stage
Public CompanyTotal Funding
$2.35B2025-11-17Post Ipo Debt· $850M
2024-11-13Post Ipo Debt· $750M
2021-11-16Post Ipo Debt· $750M
Leadership Team
Dave Reynolds
Executive Vice President, Health Plans & Medicaid Chief Operating Officer
Debbie Simkins
Vice President, Office of the CIO
Recent News
2026-01-03
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