Senior Project Manager, Claims Operations

Job Description

Job Summary

Manages people who are responsible for internal business projects and programs involving department or cross-functional teams of subject matter experts, delivering products through the design process to completion. Plans and directs schedules as well as project budgets. Monitors the project from inception through delivery. May engage and oversee the work of external vendors. Assigns, directs and monitors system analysis and program staff. These positions' primary focus is project/program management, rather than the application of expertise in a specialized functional field of knowledge although they may have technical team members.

• Expanded Scope:
• The Senior Project Manager for Claims Operations drives complex, multi-workstream initiatives that span people, process, data, and technology. Key areas include:
• Strategy & Road mapping: Translate business strategy into a prioritized project roadmap; define scope, OKRs/KPIs, value hypothesis, and measurable success criteria (e.g., first-pass resolution, auto-adjudication rate, claims cycle time, audit findings, cost-to-serve).
• Process Optimization: Lead current/future-state mapping, root cause analysis, and continuous improvement (Lean/Six Sigma). Design scalable workflows and controls across intake, adjudication, adjustments, appeals/grievances, and payment integrity.
• Technology Enablement: Oversee requirements, configuration, and testing for platforms such as Salesforce (case management, integrations), QNXT (or similar core claims), RPA/automation, and analytics/reporting (e.g., SQL/Excel, BI tools).
• Delivery Excellence: Plan and execute across Waterfall/Agile or hybrid approaches; lead UAT, cutover, and post–go‑live; steward change management (training, SOPs, job aids, communications).
• Risk, Compliance & Quality: Ensure alignment to CMS, HIPAA, state regulations, and audit readiness. Establish governance, RAID (risks/assumptions/issues/dependencies), and quality gates throughout delivery.
• Vendor & Stakeholder Management: Manage SOWs and partner performance; facilitate executive steering, operational readiness, town halls, and cross-functional standups.
• People Leadership & Culture: Model a high-performance, collaborative culture; mentor PMs/analysts; promote data-driven decision making and continuous improvement.

Knowledge/Skills/Abilities

• Project & Portfolio Leadership 
• Leads high dollar, multi-workstream programs; sets cadence (steering committees, status reports, dashboards), manages budget, resources, and critical path.
• Balances capacity across initiatives; aligns with PMO standards, stage gates, and financial controls.
• Operational & Regulatory Acumen (Healthcare/Claims) 
• Deep understanding of claims lifecycle, EDI transactions, payment integrity, provider data, appeals/grievances, and audit/compliance (CMS, HIPAA, NCQA, state regs).
• Designs and embeds controls, SLAs, and quality checks to support audit readiness and reduce rework.
• Process Improvement & Change Management 
• Applies Lean/Six Sigma for waste reduction and throughput gains
• Executes structured change management including stakeholder engagement, training plans, SOPs/job aids, and communications.
• Technical Fluency & Data Literacy 
• Translates business needs into requirements and test cases; manages integrations across Salesforce, core claims (e.g., QNXT), and data pipelines.
• Builds and interprets KPI dashboards; uses SQL/Excel or BI tools to analyze performance and inform decisions.
• Communication & Influence 
• Crafts clear exec-ready updates, risk narratives, and decision papers; negotiates tradeoffs; escalates with options and quantified impacts.
• Facilitates across operational, clinical, compliance, finance, and IT stakeholders.
• Execution Excellence 
• Strong organization, prioritization, and time management in fast-paced environments; anticipates dependency and adoption risks; drives on-time, on-budget delivery.
• Leads high dollar, multi-workstream programs; sets cadence (steering committees, status reports, dashboards), manages budget, resources, and critical path.
• Balances capacity across initiatives; aligns with PMO standards, stage gates, and financial controls.
• Deep understanding of claims lifecycle, EDI transactions, payment integrity, provider data, appeals/grievances, and audit/compliance (CMS, HIPAA, NCQA, state regs).
• Designs and embeds controls, SLAs, and quality checks to support audit readiness and reduce rework.
• Applies Lean/Six Sigma for waste reduction and throughput gains
• Executes structured change management including stakeholder engagement, training plans, SOPs/job aids, and communications.
• Translates business needs into requirements and test cases; manages integrations across Salesforce, core claims (e.g., QNXT), and data pipelines.
• Builds and interprets KPI dashboards; uses SQL/Excel or BI tools to analyze performance and inform decisions.
• Crafts clear exec-ready updates, risk narratives, and decision papers; negotiates tradeoffs; escalates with options and quantified impacts.
• Facilitates across operational, clinical, compliance, finance, and IT stakeholders.
• Strong organization, prioritization, and time management in fast-paced environments; anticipates dependency and adoption risks; drives on-time, on-budget delivery.

Tools/Methods (examples): Salesforce, QNXT (or similar core claims), JIRA/Azure DevOps, MS Project/Smartsheet, Visio/Miro/Lucid, SQL, Excel, PowerPoint, Power BI/Tableau, Confluence, ServiceNow; Lean/Six Sigma; Agile/Waterfall/Hybrid.

Job Qualifications

Required Education

• Bachelor's Degree or equivalent combination of education and experience

Required Experience

• 5-7 years of project/program management with direct impact on Claims Operations (adjudication, configuration, appeals/grievances, payment integrity, provider data).

Preferred Education

• Graduate Degree or equivalent combination of education and experience
• Formal training/coursework in project management, process improvement, change management, or healthcare operations.
• Specialized training in Salesforce administration, process mapping, UAT/QA, or data analytics. 

Preferred Experience

• 7-9 years of project/program management with direct impact on Claims Operations (adjudication, configuration, appeals/grievances, payment integrity, provider data).
• Proven leadership of multi-vendor, multi-system implementations (e.g., Salesforce + claims core + data/BI) with hybrid Agile/Waterfall delivery.
• Track record in process mapping, workflow redesign, automation (RPA/integration), and control design to improve accuracy and cycle times.
• Experience creating and delivering training, SOPs, job aids, and communications; leading readiness, cutover planning, and post–go live stabilization.
• Hands-on governance, quality assurance, risk management, and escalation handling in a regulated environment (CMS, HIPAA, state).
• Proficiency with Salesforce, QNXT (or similar), SQL, Excel, JIRA/Azure DevOps, and PM/visualization tools (MS Project/Smartsheet, Power BI/Tableau).
• Experience facilitating high-visibility forums (executive steering, town halls, implementation readiness reviews); prior people leadership or mentoring of PMs/analysts is a plus.
• Strong analytical, organizational, and communication skills; adept at managing multiple priorities and influencing across levels. 

Preferred License, Certification, Association

• PMP (Project Management Professional) strongly preferred.
• Lean Six Sigma Black Belt preferred (Green Belt considered).
• Agile/Scrum certification (e.g., CSM, PMI-ACP, SAFe) desirable.
• Salesforce Administrator or relevant platform certification a plus. 

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.