Healthcare Project Manager

****Must Live in California, Washington, or Oregon****Healthcare Project Manager Focus: Payment Integrity, Claims Processing, FWA & IT SystemsPosition Overview We are seeking an experiencedHealthcare Project Managerto lead cross-functional initiatives focused onPayment Integrity, Claims Operations, Fraud Waste & Abuse (FWA), and Healthcare IT systems . This role will drive enterprise projects that improve claims accuracy, reduce financial leakage, strengthen compliance, and optimize operational performance across payer or managed care environments. The ideal candidate brings strong healthcare domain expertise, technical fluency, and the ability to manage complex regulatory and system-driven initiatives.Key Responsibilities Project Leadership & Delivery Lead end-to-end project lifecycle (initiation through implementation and post-go-live stabilization). Develop detailed project plans, timelines, budgets, and resource allocations. Manage cross-functional stakeholders including Claims, SIU, Compliance, Finance, IT, and external vendors. Identify risks, dependencies, and mitigation strategies. Payment Integrity & Claims Processing Drive initiatives to improve claims adjudication accuracy and reduce overpayments/underpayments. Partner with Payment Integrity and SIU teams to enhance pre-payment and post-payment review programs. Oversee implementation or optimization of claims platforms (e.g., Facets, QNXT, HealthRules, etc.). Improve operational KPIs such as first-pass yield, auto-adjudication rates, TAT, and denial management. Fraud, Waste & Abuse (FWA) Support projects involving fraud detection tools, analytics models, and regulatory reporting. Collaborate with Special Investigations Unit (SIU) on compliance-driven initiatives. Ensure alignment with CMS, OIG, HIPAA, and other regulatory standards. IT & Systems Integration Lead system upgrades, data migrations, vendor integrations, and automation initiatives. Coordinate business requirements gathering and translate into technical specifications. Work with data analytics teams on reporting dashboards and predictive models. Ensure UAT planning, execution, and stakeholder sign-off. Regulatory & Compliance Oversight Ensure projects align with CMS guidelines, state Medicaid requirements, and commercial payer regulations. Support audit readiness and documentation standards. Maintain strong governance and reporting frameworks. Required Qualifications Bachelor’s degree in Healthcare Administration, Business, IT, or related field. 5+ years of project management experience within healthcare payer, managed care, or health insurance. Hands-on experience with: Payment Integrity programs Claims adjudication systems Fraud, Waste & Abuse initiatives Healthcare IT implementations Strong understanding of CMS guidelines and healthcare compliance requirements. Proven ability to manage cross-functional teams and vendor relationships. Preferred Qualifications PMP certification (preferred). Experience with claims platforms such as Facets, QNXT, HealthRules, or similar. Experience working with analytics tools (SQL, Tableau, Power BI). Background in Medicaid, Medicare Advantage, or Commercial health plans. Core Competencies Strategic thinking with operational execution Strong stakeholder communication Data-driven decision making Risk management & issue resolution Process improvement (Lean/Six Sigma a plus)