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Director, Payment Integrity
Molina HealthcareAZ, United States, United Statesfull_timeVerifiedPosted 18 Apr 2025
About the role
Job Description
Job Summary
Responsible for planning, developing and directing the implementation of techniques to ensure the maintenance of performance and quality levels in the Business' products and processes. Reviews operation process designs and establishes procedures and techniques for operational standards. Confers with customers to define and resolve
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..
Job Qualifications
Required Education
Bachelor Degree or equivalent combination of education and experience
Required Experience
5-7 years
Preferred Education
Bachelor Degree or equivalent combination of education and experience
Preferred Experience
10+ years
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 Summary
Responsible for planning, developing and directing the implementation of techniques to ensure the maintenance of performance and quality levels in the Business' products and processes. Reviews operation process designs and establishes procedures and techniques for operational standards. Confers with customers to define and resolve
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..
Job Qualifications
Required Education
Bachelor Degree or equivalent combination of education and experience
Required Experience
5-7 years
Preferred Education
Bachelor Degree or equivalent combination of education and experience
Preferred Experience
10+ years
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.
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