Program Manager, Health Plan Payment Integrity (Claims & Recovery)

Accountabilities: Lead and manage health plan payment integrity initiatives, providing subject matter expertise across recovery concepts, operational processes, and business solutions. Own and execute scoreable action items (SAIs), ensuring performance targets, quality standards, and operational objectives are achieved. Oversee projects and activities that support CMS and state regulatory requirements for pre-payment edits, post-payment data mining, and overpayment recovery. Manage payment integrity inventory in collaboration with relevant teams to ensure recovery targets and deliverables are met. Drive improvements in claims payment accuracy, claim referrals, adjustment analysis, and financial performance. Identify payment integrity issues, claims trends, and process gaps, and develop effective strategies to address them. Collaborate with operational teams, enterprise stakeholders, finance, compliance, and network partners to resolve complex challenges and support business priorities. Provide strategic recommendations and serve as a trusted advisor to health plan leadership, contributing to both short- and long-term goals. Coordinate with network and provider relations teams to communicate recovery initiatives and ensure they are prepared to address provider questions. Apply knowledge of healthcare regulations, managed care claims workflows, provider contracts, and reimbursement models to develop actionable business requirements and solutions. Use data analysis tools and queries to validate findings, test assumptions, and assess operational performance. Prepare concise data summaries and visualizations that help leadership make informed decisions. Partner with finance and compliance teams to develop business cases and reporting that connect operational outcomes with financial targets. Requirements: 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, or an equivalent combination of relevant education and experience. Demonstrated experience managing operational projects from initial concept through execution, particularly in provider reimbursement and claims payment integrity. Strong understanding of managed care claims processing, reimbursement, and coding systems, including CPT, ICD, HCPCS, and revenue codes. Knowledge of federal and state Medicaid payment regulations and requirements. Experience in payment integrity, cost management, claims recovery, or related healthcare claims operations. Strong data analysis and querying capabilities, with the ability to interpret findings and use data to support business decisions. Excellent analytical and problem-solving skills, including the ability to navigate complex or ambiguous challenges independently. Strong business judgment and a demonstrated ability to take ownership of high-value deliverables in a regulated, cross-functional environment. Excellent written and verbal communication skills, including the ability to synthesize complex information and present clear recommendations to different audiences. Ability to collaborate effectively with operational teams, enterprise stakeholders, and leadership at multiple levels. Proficiency in Microsoft Office, particularly advanced Excel, and other relevant business software. Preferred: Experience with Medicare, Medicaid, and/or Marketplace lines of business, with Kentucky Medicaid experience considered an advantage. Preferred: Certified Business Analysis Professional (CBAP) or Certified Coding Specialist (CCS) certification. Preferred: Project management experience and familiarity with Medicaid-specific SAIs, payment integrity programs, operational cost-management initiatives, and regulatory compliance. Benefits: Annual salary range of $69,447 to $135,421 , with actual compensation varying according to geographic location, professional experience, education, and skill level. Full-time remote work arrangement. Competitive compensation and benefits package. Opportunity to contribute to initiatives that improve healthcare payment accuracy, operational efficiency, and financial performance. Collaborative work environment involving cross-functional teams and health plan leadership.