Payment Integrity Program Manager - Health Plan (Nevada)

Job Title

Provides subject matter expertise and responsibility for oversight, production, and resolution of Health Plan Payment Integrity (PI) recovery concepts. Executes and monitors 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 and executes tasks and projects to ensure Centers for Medicare & Medicaid Services (CMS) and State regulatory requirements are met for Pre-pay Edits & Overpayment Recovery. Manages inventory and works in collaboration with PI Team to ensure Health Plan SAI targets are met. The role 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.

Job Duties

Business Leadership & Operational Ownership

• Independently owns and manages Scorable Action Items (SAIs) including assisting and executing projects and tasks to ensure CMS and State regulatory requirements are met for pre-pay edits, post payment datamining, and overpayment recovery which improves encounter submissions, reduces General and Administrative expenses (G&A) costs, and continues to drive positive operational and financial outcomes for all PI solutions.
• Leads efforts to improve claim payment accuracy, claim referrals, adjustment analysis and financial performance without needing extensive oversight.
• 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 provide well-reasoned recommendations that support short- and long-term business goals.
• Partners with Network to communicate recovery projects so that provider relations can be informed and respond to questions from providers.

Strategic Business Analysis

Applied Analytical Support

Job Qualifications

Required Qualifications :

Preferred Qualifications :

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V. Pay Range : $76,757 - $149,676 / ANNUAL