Job Description
JOB DESCRIPTION Job Summary
Provides audit support for Molina enterprise risk adjustment activities. Responsible for developing, recommending and implementing controls and cost-effective approaches to minimize the organization's risks effects. Identifies and analyzes potential sources of loss to minimize risk, and estimates the potential financial consequences of an occurring loss. Through the proper combination of casualty and liability insurance, ensures that the provider organization is adequately protected against financial loss.
Essential Job Duties
• Facilitates daily operations of all aspects of risk adjustment data validation and audit-related activities, including but not limited to: progress tracking, chart retrieval, file transmissions, and adherence to applicable timelines.
• Represents as a risk adjustment audit liaison with functional departments, health plans, and external vendors.
• Evaluates results from audit activities to address barriers, gaps, opportunities for improvement, and implement corrective action plans (CAPs) as necessary.
• Oversees Risk Adjustment Processing System (RAPS) and Encounter Data Processing System (EDPS) data transmissions, and assists in identification of issues that impact data integrity and accuracy.
• Develops and implements processes and procedures to ensure accuracy, completeness, and compliance with Centers for Medicare and Medicaid Services (CMS) regulations and guidelines of risk adjustment data.
• Identifies opportunities for data mining to ensure data gaps are minimized.
• Applies best practices to ensure accuracy of risk adjustment payment in all markets.
• Supports all risk adjustment audit related projects to ensure goals, objectives, milestones and deliverables are met.
• Performs monthly audits on internal Molina coding specialist performance..
• Facilitates audits on external Molina vendor performance.
Required Qualifications
• At least 3 years of coding, medical record chart review, and risk adjustment data validation experience, or equivalent combination of relevant education and experience.
• Certified Coding Specialist (CCS), Certified Coding Specialist -Physician-based (CCS-P), or Certified Professional Coder (CPC).
• Excellent attention to detail, documentation and organizational skills.
• Critical-thinking, problem-solving and analytical skills.
• Ability to work independently in a fast-paced, deadline-driven environment.
Ability to work cross-collaboratively in a highly matrixed environment, including ability to communicate audit findings with internal teams.
• Strong verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency, and ability to learn new information systems and software programs.
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
Job Info
Job Identification: 2038402
Job Category: Quality & Risk Adjustment
Posting Date: 2026-07-16T19:07:22 00:00
Job Schedule: Full time
