JOB DESCRIPTION
Job Summary
Responsible for leading the strategy, governance, implementation, maintenance, and optimization of the organization’s Payment Integrity post-pay data mining program.
This role leads a team of Business Analysts, Data Engineers and Data Analysts, responsible for developing and maintaining concept requirements, analytical logic and workflow solutions supporting Molina’s portfolio of post pay concepts.
The Director provides both business and technical leadership across the concept lifecycle, ensuring healthcare reimbursement policies, coding requirements, and payment integrity opportunities are translated into accurate, scalable, and maintainable analytical solutions.
The Director serves as a key liaison between Health Plans and Executive Leadership teams. 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 and ensures consistent governance, methodology, and performance management across markets.
- Provide technical oversight of concept development and maintenance, including SQL-based analytical logic, Databricks solutions, and Azure DevOps work management.
- Leads enterprise projects and large-scale initiatives that drive financial improvement, cost containment, and operational transformation.
- Lead, mentor, and develop a team of Business Analysts, Data Engineers, and Data Analysts responsible for concept research, documentation, technical development, implementation, and ongoing maintenance.
- Establishes departmental goals, KPIs, and performance reporting mechanisms that measure and communicate enterprise payment integrity outcomes.
- Represents Payment Integrity at enterprise governance meetings, shared services councils, and external regulatory discussions.
- Champions innovation through automation, advanced analytics, and data-driven decision-making.
- Establish performance expectations, development plans, and succession strategies that support organizational growth and talent development.
- Translate healthcare reimbursement policies, coding guidelines, and business opportunities into actionable business requirements and analytical solutions.
- 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
- Advanced knowledge of SQL and experience reviewing or providing oversight of production-level SQL logic.
- Hands-on experience with Databricks and Azure DevOps, including notebooks, workflows, data pipelines, or related development and analytical capabilities.
- 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.
- 5 years of leadership experience managing teams responsible for payment integrity analytics, claim configuration, claims auditing, or related analytical 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
