Job Description

Job Summary

The Payment Integrity Program Manager - Health Plan is a subject matter expert, individual contributor role designed for a highly capable business analyst who serves as a key strategic partner in driving health plan financial performance. This role focuses on identifying, leading, and executing operational initiatives tied to Payment Integrity (PI) and provider claims accuracy. The individual will be relied upon to make independent, informed decisions, contribute to health plan strategy, and act as a trusted voice in resolving complex business challenges that impact cost containment and regulatory compliance. The position requires strong business judgment, cross-functional coordination, and ownership of high-value deliverables—distinct from a pure data analyst role.

 

Job Duties

Business Leadership & Operational Ownership Independently own and manage Scorable Action Items (SAIs) related to pre-pay editing, post-pay audit, and overpayment recovery initiatives. Lead efforts to improve claim payment accuracy and financial performance without needing extensive oversight. Collaborate with operational teams, enterprise stakeholders, and finance partners to proactively identify issues and implement resolution strategies. Serve as a thought partner to health plan leadership and provide well-reasoned recommendations that support short- and long-term business goals. Strategic Business Analysis Use a business lens to interpret provider claims trends, payment integrity issues, and process gaps. Apply understanding of healthcare regulations, managed care claims workflows, and provider reimbursement models to shape recommendations and action plans. Translate strategic needs into clear requirements, workflows, and solutions that drive measurable improvement. Partner with finance and compliance to develop business cases and support reporting that ties operational outcomes to financial targets. Applied Analytical Support Use Excel and SQL as tools to support business analysis, not as the core function of the role. Validate findings and test assumptions through data, but lead with contextual knowledge of claims processing, provider contracts, and operational realities. Create succinct summaries and visualizations that enable faster decision-making by leadership—not raw data exploration.

 

Job Qualifications

REQUIRED QUALIFICATIONS:

Bachelor’s Degree in Business Administration, Healthcare Management or related field (or equivalent experience). At least 5 years of experience as a Business Analyst or Program Manager in a Managed Care Organization (MCO) or health plan setting. 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 (CPT, ICD, HCPCS, Revenue Codes), and federal/state Medicaid payment rules. Skilled in Excel and SQL, with the ability to analyze data to inform business decisions—but not dependent on technical guidance for action. Demonstrated ability to work independently and apply business judgment in a highly regulated, cross-functional environment.

PREFERRED QUALIFICATIONS:

CBAP, or Certified Coding Specialist (CCS) certification. Project Management Experience Familiarity with Medicaid-specific Scorable Action Items (SAIs), Operational Cost Management Efforts, Payment Integrity programs, and regulatory/compliance adherence. 

 

 

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.