JOB DESCRIPTION
Job Summary
Responsible for leading the strategic development, governance, implementation, maintenance, and optimization of the organization's post-pay payment integrity concept portfolio. This role leads a team of Business Analysts responsible for maintaining concept white papers, business requirements, operational specifications, and enhancement requests supporting Molina’s portfolio of post pay concepts.
The Director serves as a key liaison between Health Plans, Data Science, and Executive Leadership teams to ensure payment integrity concepts are effectively developed, implemented, maintained, and optimized to achieve financial and operational objectives. This position oversees a high-volume, fast-paced environment supporting concept lifecycle management, stakeholder engagement, and continuous improvement initiatives.
Essential Job Duties
- Develop and execute the strategic roadmap for the post-pay payment integrity concept portfolio, ensuring alignment with organizational financial, operational, and regulatory objectives.
- Oversee the end-to-end lifecycle of payment integrity concepts, including intake, prioritization, requirements development, implementation, testing, deployment, maintenance, enhancement, and retirement.
- Champion and drive continuous improvement initiatives that enhance scalability, automation, productivity, and concept performance.
- Lead, mentor, and develop a team of Business Analysts responsible for concept white papers, business requirements, enhancement requests, and concept maintenance activities.
- Establish performance expectations, development plans, and succession strategies that support organizational growth and talent development.
- Ensure the accuracy, consistency, and governance of concept white papers, business requirements, operational specifications, and supporting documentation.
- Provide oversight of concept change management, maintenance activities, and enhancement requests to ensure timely and accurate delivery.
- Translate healthcare reimbursement policies, coding guidelines, and business opportunities into actionable business requirements and analytical solutions.
- Develop standards and best practices for concept documentation, requirements management, testing, and implementation.
- Serve as the primary business leader and escalation point for health plans regarding concept methodologies, performance, implementation questions, maintenance activities, and enhancement requests.
- Support organizational initiatives that improve payment accuracy, reduce administrative burden, and maximize recovery opportunities.
- Ensure compliance with regulatory requirements, reimbursement policies, coding standards, and organizational governance practices.
- Monitor industry trends, regulatory changes, and emerging payment integrity opportunities to inform strategic direction and concept development priorities.
Required Qualifications
- At least 8 years of experience supporting health care operations, including 5 years payment integrity/claims experience, or equivalent combination of relevant education and experience.
- At least 3 years management/leadership experience.
- Managed care payor experience, preferably in Medicare/Medicaid government-sponsored programs.
- Ability to establish and maintain positive and effective work relationships with coworkers, members, providers and customers.
- Strong organizational and time-management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
- Excellent verbal and written communication skills.
- Microsoft Office suite and applicable software program(s) proficiency.
Preferred Qualifications
- Knowledge of CPT, HCPCS, ICD-10-CM, ICD-10-PCS, NCCI, DRG, and reimbursement methodologies.
- Strong understanding of healthcare claims processing, reimbursement methodologies, coding systems, and payment integrity principles.
- Experience developing and managing business requirements, process documentation, or operational specifications.
- Experience managing payment integrity concept governance, portfolio management, and health plan engagement functions.
- 5 years of leadership experience managing teams responsible for payment integrity analytics, claim configuration, claims auditing, or related functions.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
