Program Manager, Health Plan Payment Integrity (Claims & Recovery)
Core
Lead payment integrity initiatives to improve claims accuracy, strengthen cost management, and support regulatory compliance across health plan operations.
Role type
Senior Program Manager, Health Plan Payment Integrity
Builds
Recovery programs, pre-payment edits, post-payment analysis, and overpayment recovery strategies
Domain
Healthcare / Managed Care / Insurance
Required skills
Managed care claims processing, reimbursement, and coding systems (CPT, ICD, HCPCS, revenue codes), Medicaid and Medicare program experience, payment integrity and cost management, data analysis and querying, regulatory compliance knowledge, project management
Preferred skills
Kentucky Medicaid experience, CBAP or CCS certification, project management with Medicaid-specific SAIs
Technologies
Microsoft Office (Advanced Excel), data analysis tools
Responsibilities
Lead and manage health plan payment integrity initiatives, own and execute scoreable action items (SAIs), oversee projects supporting CMS and state regulatory requirements, manage payment integrity inventory, drive improvements in claims payment accuracy and financial performance, identify payment integrity issues and develop strategies, collaborate with operational teams and stakeholders, provide strategic recommendations to leadership, coordinate with network and provider relations teams, apply knowledge of healthcare regulations to develop business requirements, use data analysis tools to validate findings and assess performance, prepare data summaries and visualizations for leadership, partner with finance and compliance teams to develop business cases
Seniority
Senior, hands-on IC
