VP, Payment Integrity - REMOTE

This VP, Payment Integrity position offers strategic leadership and expertise to Molina's cross-functional Payment Integrity organization. You'll drive efficiencies, explore new opportunities, and leverage technology to achieve goals, minimize costs, and improve performance. This is a remote position.

💼 What You'll Do

• Lead Molina’s Payment Integrity Content Ideation, Research, and Edit Development teams.
• Identify and validate concepts, conduct root cause analysis, and optimize content to minimize dispute overturn rates.
• Provide leadership and vision to maximize accurate overpayment recovery while driving prevention efforts and cost savings.
• Lead pre-pay and post-pay programs to expand overpayment identification, improve recovery, and manage administrative costs.
• Contribute to the strategy, design, and implementation of payment accuracy initiatives impacting core claims operations (under the direction of the SVP Payment Integrity).
• Develop strategies for outsourcing, technology enablement, and process efficiencies to meet goals and minimize administrative expenses.
• Ensure achievement of financial objectives and operational excellence.
• Identify technical improvements to expand concept ideation (e.g., database connections, report monitoring, automation).
• Collaborate with Health Plan or Shared Service leadership to identify new opportunities and translate business requirements for the technical team.
• Analyze SLAs, team performance, and plan continuous improvement in performance, process optimization, reporting, and documentation.
• Participate in monthly business review meetings with executive leadership and stakeholders, ensuring issue resolution.
• Oversee Claims Adjudication accuracy (QNXT configuration, Claims Production, Audit, Vendor Oversight) across all lines of business. This includes supporting Claims Shared Services (Corporate Recovery Team, Corporate Claims Compliance Team, Support Services, Enrollment and Billing, Corporate Encounter Team) and managing claims editing and recovery vendors.
• Manage QNXT system configuration for all lines of business, including the Care Management application for UM functions. This involves meeting state regulatory requirements, optimizing healthcare cost production, maximizing MASS Adjudication, improving provider payment quality, and reducing G&A costs.

💪 What You'll Need

• Required Education: Bachelor’s Degree or equivalent relevant healthcare experience.
• Required Experience:
  • Minimum 10 years of healthcare experience in a related role or operational experience.
  • Proven success in Payment Integrity, preferably leading content development.
  • 5+ years of Managed Care payor experience (Medicare/Medicaid preferred).
  • 5+ years of senior-level leadership experience.
  • Technical experience/understanding of data systems and edit configuration (SQL, Databricks, etc.).
  • Strong strategic thinking, ability to translate strategy into operational goals, excellent collaboration, financial, analytical, and change management skills.
  • Strategic and growth mindset, proven ability to build consensus and alignment with executive stakeholders.
  • Excellent verbal and written communication and organizational skills.
  • Ability to influence and drive change.
  • Ability to develop and implement payment ideation initiatives and systems.
  • HIPAA compliance knowledge.
  • Ability to build positive work relationships.
  • Willingness to travel (limited).
• Preferred Education: Master’s Degree