Program Manager, Health Plan Payment Integrity (Claims & Recovery)
New
J
JobgetherHealth plan operations
Based in the United StatesFull-TimeManager
Salary69,447 - 135,421 USD per year
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Job Details
- Experience
- At least 5 years of business analyst experience within a managed care organization (MCO), and at least 3 years of experience working with Medicaid and/or Medicare programs
- Required Skills
- Project Management
Requirements
- Have at least 5 years of business analyst experience within a managed care organization (MCO) and at least 3 years working with Medicaid and/or Medicare programs, or equivalent education and experience.
- Demonstrate experience managing operational projects from concept through execution, particularly in provider reimbursement and claims payment integrity.
- Understand managed care claims processing, reimbursement, and coding systems, including CPT, ICD, HCPCS, and revenue codes.
- Know federal and state Medicaid payment regulations and requirements.
- Bring experience in payment integrity, cost management, claims recovery, or related healthcare claims operations.
- Demonstrate data analysis and querying capabilities and the ability to use findings to support business decisions.
- Apply analytical and problem-solving skills to complex or ambiguous challenges.
- Show business judgment and ownership of high-value deliverables in a regulated, cross-functional environment.
- Communicate complex information and recommendations clearly in writing and verbally to different audiences.
- Collaborate with operational teams, enterprise stakeholders, and leadership at multiple levels.
- Be proficient in Microsoft Office, particularly advanced Excel, and other relevant business software.
- Medicare, Medicaid, and/or Marketplace lines of business experience is preferred; Kentucky Medicaid experience is an advantage.
- CBAP or CCS certification, project management experience, and familiarity with Medicaid-specific SAIs, payment integrity programs, operational cost management, and regulatory compliance are preferred.
Responsibilities
- Lead health plan payment integrity initiatives and provide expertise across recovery concepts, operational processes, and business solutions.
- Own and execute scoreable action items (SAIs) to meet performance targets, quality standards, and operational objectives.
- Oversee projects supporting CMS and state requirements for pre-payment edits, post-payment data mining, and overpayment recovery.
- Manage payment integrity inventory with relevant teams to meet recovery targets and deliverables.
- Improve claims payment accuracy, claim referrals, adjustment analysis, and financial performance.
- Identify payment integrity issues, claims trends, and process gaps, and develop strategies to address them.
- Collaborate with operational teams, enterprise stakeholders, finance, compliance, and network partners to resolve challenges.
- Advise health plan leadership and provide strategic recommendations aligned with short- and long-term goals.
- Coordinate with network and provider relations teams to communicate recovery initiatives and prepare for provider questions.
- Analyze data, validate findings, prepare summaries and visualizations, and partner with finance and compliance on business cases and reporting.
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