- Salary Range: $59810.6 - $129589.63 ~Annually *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
JOB DESCRIPTION Job Summary
Provides lead level support for COB-specific claim pricing audits. Responsible for accurate and timely implementation and maintenance of critical information on claims/provider databases, validating data housed on databases and ensuring adherence to business and system requirements. Facilitates end-to-end claim audits, maintains audit records, provides counsel regarding coverage amount/benefit interpretation within the audit process, monitors and controls backlog and workflow of audits, and ensures that audits are completed in a timely fashion and in accordance with audit standards.
Essential Job Duties
- Accurately interprets end-to-end business requirements, and confirms that outcomes meet specific state/federal requirements.
- Creates reporting tools to enhance audit communications on configuration accuracy results and/or audit findings
- Writes complex ad-hoc reports related to configuration/claims.
- Interprets and validates accuracy of complex reports and automated configuration processes/solutions.
- Leads peer review processes.
- Interprets complex business problems and technical issues related to configuration oversight.
- Effectively communicates audit findings and/or outcomes through review meetings, written communications, and, workflow diagrams.
- Demonstrates understanding of the claims system functionality and schema
- Researches and reviews new audit tools and techniques and provides recommendations to leadership.
- Develops and maintain standards and best practices
- Participates in and/or leads project meetings.
- Manages complex projects from requirements to deployment, including work assignment, prioritization, issue triage etc.
- Researches complex claims/configuration issues.
- Assists leadership in establishing peer review standards, methodologies, guidelines, and best practices for the configuration oversight audit team.
- Represents as a team lead and configuration oversight subject matter expert - assigns and prioritizes work as needed.
- Provides training and support to new and existing team members; ensures team members receive training and support related to functionality, enhancements and updates.
- Manages fluctuating volumes of work, and prioritizes work to meet deadlines and needs of the configuration department and user community.
Required Qualifications
- At least 5 years of claims auditing experience within a health care operations setting in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or equivalent combination of relevant education and experience.
- Expert experience/understanding of claims processes and claims auditing.
- Expert experience identifying and troubleshooting claim discrepancies by utilizing benefit and provider contracts, regulatory requirements and various claims related resources.
- Expert experience validating and confirming information related to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other business requirements.
- Expert experience verifying documentation related to updates/changes within claims processing system.
- Strong analytical and critical-thinking skills.
- Flexibility to meet changing business requirements, and commitment to high-quality/on-time delivery.
- Process improvement experience.
- High attention to detail.
- Strong verbal and written communication skills.
- Microsoft Office suite proficiency, including intermediate to advanced Excel abilities (VLOOKUP/Pivot Tables, etc.), and applicable software programs proficiency.
Preferred Qualifications
- Experience mentoring and/or training peers.
- Bachelor's degree
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
