Program Manager, Health Plan Payment Integrity (Claims & Recovery)

This is an opportunity for an experienced healthcare professional to lead payment integrity initiatives that improve claims accuracy, strengthen cost management, and support regulatory compliance across health plan operations. In this role, you will oversee recovery programs, manage key performance action items, and drive projects focused on pre-payment edits, post-payment analysis, and overpayment recovery. You will work closely with claims, finance, compliance, network, and operational teams to identify issues and deliver effective solutions. Combining managed care expertise with strong analytical and business judgment, you will translate complex challenges into actionable strategies and measurable results. This is a full-time remote position in a highly regulated, cross-functional environment.

• At least 5 years of business analyst experience within a managed care organization (MCO), and at least 3 years of experience working with Medicaid and/or Medicare programs, or an equivalent combination of relevant education and experience.

• Demonstrated experience managing operational projects from initial concept through execution, particularly in provider reimbursement and claims payment integrity.

• Strong understanding of managed care claims processing, reimbursement, and coding systems, including CPT, ICD, HCPCS, and revenue codes.

• Knowledge of federal and state Medicaid payment regulations and requirements.

• Experience in payment integrity, cost management, claims recovery, or related healthcare claims operations.

• Strong data analysis and querying capabilities, with the ability to interpret findings and use data to support business decisions.

• Excellent analytical and problem-solving skills, including the ability to navigate complex or ambiguous challenges independently.

• Strong business judgment and a demonstrated ability to take ownership of high-value deliverables in a regulated, cross-functional environment.

• Excellent written and verbal communication skills, including the ability to synthesize complex information and present clear recommendations to different audiences.

• Ability to collaborate effectively with operational teams, enterprise stakeholders, and leadership at multiple levels.

• Proficiency in Microsoft Office, particularly advanced Excel, and other relevant business software.

• Preferred: Experience with Medicare, Medicaid, and/or Marketplace lines of business, with Kentucky Medicaid experience considered an advantage.

• Preferred: Certified Business Analysis Professional (CBAP) or Certified Coding Specialist (CCS) certification.

• Preferred: Project management experience and familiarity with Medicaid-specific SAIs, payment integrity programs, operational cost-management initiatives, and regulatory compliance.