Director, Payment Integrity (Payer Operations / Vendor Oversight) - REMOTE

• 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 QualificationsRequired 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.

Job Info

Job Identification: 2028473

Job Category: Operations

Posting Date: 2024-12-06T23:44:22 00:00

Job Schedule: Full time