Clinical Program Manager- Payment Integrity - Health Plan (Kentucky)

Job Summary

For this position we are seeking a (RN) Registered Nurse who must be licensed for the state of KENTUCKY or have a compact license.

Provides subject matter expertise and responsibility for oversight, production, and resolution of Health Plan Payment Integrity (PI) recovery concepts. This role executes and monitors Health Plan Scorable Action Items (SAIs) to ensure performance and quality levels exist in PI Business products and processes. Establishes procedures and techniques to achieve operational goals and executes tasks and projects to ensure Centers for Medicare & Medicaid Services (CMS) and State regulatory requirements are met for Pre-pay Edits & Overpayment Recovery. Manages inventory and works in collaboration with PI Team to ensure Health Plan SAI targets are met. The role will be relied upon to make independent, informed decisions, contribute to health plan strategy, and act as a trusted voice in resolving complex business challenges that impact cost containment and regulatory compliance. The position requires strong business judgment, cross-functional coordination, and ownership of high-value deliverables.

Job Duties

• Develop and execute effective Payment Integrity strategies through both pre-payment and post payment claims reviews, aligning with industry and corporate standards as well as the professional scope of a Payment Integrity Clinician. This includes assessing medical documentation, itemized bills, and claims data to ensure appropriate payment levels, optimize resource utilization, and maintain compliance with state and federal laws. All reviews must be conducted in accordance with accepted coding criteria, established guidelines, and relevant payment and medical policies, with a consistent focus on promoting the quality, accuracy, and efficiency of review services.
• Serve as a resource and subject matter expert to colleagues with less experience, providing ongoing support to collaboratively resolve Payment Integrity Review issues of moderate to high complexity.
• Independently owns and manages savings initiatives by proactively identifying, validating, and tracking cost containment initiatives through comprehensive clinical and financial analysis of claims data, medical documentation, and itemized bills.
• Leads efforts to improve claim payment accuracy, claim referrals, adjustment analysis and financial performance without needing extensive oversight.
• Collaborates with operational teams, enterprise stakeholders, and finance partners to proactively identify issues and implement resolution strategies.
• Serves as a thought partner to health plan leadership and provide well-reasoned recommendations that support short- and long-term business goals.
• Partners with Network to communicate recovery projects so that provider relations can be informed and respond to questions from providers.

• Uses a business lens to ensure accurate interpretation of provider claims trends, payment integrity issues, and process gaps.
• Applies understanding of healthcare regulations, managed care claims workflows, and provider reimbursement models to shape recommendations and action plans.
• Translates strategic needs into clear requirements, workflows, and solutions that drive measurable improvement.
• Partners with finance and compliance to develop business cases and support reporting that ties operational outcomes to financial targets.

• Uses Excel and Structured Query Language (SQL) as tools to support business analysis, not as the core function of the role.
• Validates findings and test assumptions through data, but lead with contextual knowledge of claims processing, provider contracts, and operational realities.
• Creates succinct summaries and visualizations that enable faster decision-making by leadership—not raw data exploration.

Job Qualifications

REQUIRED QUALIFICATIONS:

• Experience demonstrating knowledge of CMS Guidelines, MCG, InterQual or other medically appropriate clinical guidelines, Medicaid, Medicare, CHIP and Marketplace, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines.
• At least 3 years of Experience with Medicaid and/or Medicare.
• Proven experience owning operational projects from concept to execution, especially in the areas of provider reimbursement and claims payment integrity.
• Strong working knowledge of managed care claims coding (Current Procedural Terminology (CPT), International Classification of Diseases (ICD), Healthcare Common Procedure Coding System (HCPCS), Revenue Codes), and federal/state Medicaid payment rules.
• Skilled in Excel and SQL, with the ability to analyze data to inform business decisions—but not dependent on technical guidance for action.
• Demonstrated ability to work independently and apply business judgment in a highly regulated, cross-functional environment.
• Excellent written and verbal communication skills including ability to synthesize complex information.

PREFERRED QUALIFICATIONS:

• 5+ years Clinical Nursing experience, including hospital acute care/medical experience (STRONGLY DESIRED)
• Registered Nurse with Claims and CIC coding experience (STRONGLY DESIRED)
• Experience with Medicare, Medicaid, and Marketplace lines of business.
• Project Management Experience.
• Familiarity with Medicaid-specific Scorable Action Items (SAIs), Operational Cost Management Efforts, Payment Integrity programs, and regulatory/compliance adherence.

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.

Pay Range: $69,447 - $135,421 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

ABOUT US

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.