Job Description

Job Summary

This role is responsible for planning, developing, and implementing strategies to maintain high performance and quality standards in the organization's Payment Integrity Coordination of Benefits (COB) division. Manage an internal operational team as well as contracted vendors supporting outsourced functions. Key duties include optimizing operational process designs, setting procedural standards, and overseeing vendor operations to ensure compliance with key performance indicators (KPIs) and service level agreements (SLAs). The role also involves monitoring performance trends, collaborating with stakeholders, and coordinating with IT, vendors, and business teams to drive operational and technical enhancements.

Knowledge/Skills/Abilities

• With direction from the VP or AVP of Payment Integrity, leads the implementation of companywide initiatives that would include one or all of the following areas: Overpayment Recovery, Pre- and Post-pay COB, Subrogation, Premium Enhancement (such as ESRD and Medicare Secondary Payer) and Pre-pay Editing for correct coding and medical payment polices. Many of these activities include oversight of vendors that are supplemental to internal processes and activities.

• Provides leadership to team members and responsible for assigning projects and activities involving inventory management, informational reporting, database configuration, procedures and workflows to ensure quality control and timely turnaround.

• Responsible for facilitating meetings with health plans and vendors for ideation and approval of Payment Integrity initiatives.

• Provides assessments and business rules to Corporate Configuration for COB tables and Claims edits logic in the QNXT system as well as maintenance to the internal Payment Integrity Tracking databases.

• Ensures CMS and state regulatory requirements are met, for Pre-pay Edits, Overpayment Recovery, COB and Subrogation, which improves encounter submissions, reduces G&A costs, and continues to drive positive operational and financial outcomes for all solutions.

Key Responsibilities

• Strategic Leadership:

• Lead Payment Integrity initiatives in areas such as Overpayment Recovery, Pre- and Post-pay Coordination of Benefits (COB), and Subrogation under AVP direction.

• Oversee vendor operations to ensure seamless execution and compliance with organizational objectives.

• Team and Project Management:

• Manage cross-functional projects from requirements gathering to implementation and monitoring.

• Supervise team activities, including inventory management, reporting, workflow development, and quality control.

• Vendor Oversight:

• Ensure vendor adherence to KPIs, SLAs, and regulatory standards.

• Monitor performance, identify improvement opportunities, and implement corrective actions.

• Present monthly operational reviews to leadership, including metrics, trends, and updates on process improvements.

• Stakeholder Collaboration:

• Facilitate meetings with health plans and vendors to enhance efficiency, compliance, and quality.

• Adhere to change management protocols and document requirements in Business Requirement Documents (BRDs).

Job Qualifications

Required Education

Bachelor's degree or equivalent combination of education and experience.

Required Experience

• 5–7 years of relevant experience in Payment Integrity or Payer Operations.

• Vendor oversight and leadership reporting experience, including presenting metrics and trends to leadership.

• Experience performing detailed root cause analysis of technical and/or operational processes.

Preferred Education

Master's degree or equivalent combination of education and experience.

Preferred Experience

• 10+ years in Payment Integrity.

• Coordination of Benefits experience.

• Experience with BPaaS solutions and Medicaid Managed Care programs.

• Strong understanding of SQL and relational databases.

• Proven success managing initiatives with multiple stakeholders and complex workflows.

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.

Pay Range: $97,299 - $227,679 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.