Program Manager, Health Plan Integrity

Job Summary

A company is looking for a Program Manager, Health Plan Payment Integrity.

Key Responsibilities

• Manage scorable action items (SAIs) to ensure compliance with CMS and state regulatory requirements
• Lead initiatives to enhance claim payment accuracy and financial performance
• Collaborate with various teams to identify issues and implement effective resolution strategies

Required Qualifications

• Minimum of 5 years of business analyst experience in a managed care organization, with at least 3 years in Medicaid and/or Medicare programs
• Proven experience managing operational projects related to provider reimbursement and claims payment integrity
• Strong knowledge of managed care claims coding and federal/state Medicaid payment rules
• Experience in data analysis and the ability to utilize data for informed business decisions
• Demonstrated ability to work independently in a regulated, cross-functional environment