Molina Healthcare is hiring for a Health Plan Operations, Payment Integrity Program Manager. This role is fully remote.

This Program Manager role will be responsible for oversight, production, and resolution of Health Plan Payment Integrity (PI) recovery concepts. Execute and monitor Health Plan Scorable Action Items (SAIS) to ensure performance and quality levels exist in PI Business products and processes. Establishes procedures and techniques to achieve operational goals. Manages inventory and works in collaboration with PI Team to ensure Health Plan SAI targets are met. 

With direction from the Operations Leader, supports implementation and execution of department initiatives that would include one or all the following PI areas: 

Overpayment Recovery Post Payment Datamining Pre-pay Editing for correct coding and medical payment policies.  Claim Payment and Adjustment Analysis projects. Prioritizes recovery processing, offset reconciliation, refund posting and reconciliation, supports provider dispute resolution,  Supports claim referrals and Health Plan special projects. Review of Draft Coding/Payment Policies against state and federal regulatory and contractual guidance to provide feedback to Payment Integrity and coordinate HP and/or regulatory approval as needed. Review of proposed SAI concepts against state and federal regulatory and contractual guidance to provide feedback to Payment Integrity and coordinate HP and/or regulatory approval as needed. Partner with Government Contracts team to review, interpret, and confirm state-specific requirements that impact development and deployment of SAIs.

Highly Qualified Applicants Will Have the Following Experience:

Expertise in claim coding and state/CMS regulations Strong analytical background- gathering/reviewing large data sets and making sense of it Data mining and SQL experience Coding certificate or license Claims knowledge

Job Duties

Active collaborator with people who are responsible for internal business projects and programs involving department or cross-functional teams of subject matter experts, delivering products through the design process to completion. Plans and directs schedules as well as project budgets. Monitors the project from inception through delivery. May engage and oversee the work of external vendors. Focuses on process improvement, organizational change management, program management and other processes relative to the business. Leads and manages team in planning and executing business programs. Serves as the subject matter expert in the functional area and leads programs to meet critical needs. Communicates and collaborates with customers to analyze and transform needs and goals into functional requirements. Delivers the appropriate artifacts as needed. Works with operational leaders within the business to provide recommendations on opportunities for process improvements. Creates business requirements documents, test plans, requirements traceability matrix, user training materials and other related documentations.

REQUIRED EDUCATION: Bachelor's Degree or equivalent combination of education and experience.

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

3-5 years of Program and/or Project management experience. Operational Process Improvement experience. Healthcare experience. Experience with Microsoft Project and Visio. Excellent presentation and communication skills. Experience partnering with different levels of leadership across the organization.

PREFERRED EDUCATION: Graduate Degree or equivalent combination of education and experience.

PREFERRED EXPERIENCE:

5-7 years of Program and/or Project management experience. Managed Care experience. Experience working in a cross functional highly matrixed organization.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

PMP, Six Sigma Green Belt, Six Sigma Black Belt Certification and/or comparable coursework desired.

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.

Same Posting Description for Internal and External Candidates