Job Description
JOB DESCRIPTION Job Summary
Provides lead level analyst support for accurate and timely implementation and maintenance of audit programs. Also provides lead level analyst support for QA of post payment recovery concepts.
Validates data housed on databases and ensuring adherence to business and system requirements as they pertain to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other business requirements critical to claim and payment accuracy.
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. Initial primary audit focus will be on executing on a transplant audit across the organization
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 scripts and other configuration update scripts.
• Interprets and validates accuracy of complex reports and automated configuration processes/solutions.
• Leads peer review processes.
• Validates accuracy of new complex configuration processes/solutions.
• Verifies accuracy of medical record and diagnosis transmission (MRDT), fee schedule, premium, and other file load packages.
• 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.
• Helps drive solutions to successful implementation by directing technical and business resources during all phases of the software development lifecycle (SLDC).
• Leverages deep understanding of Molina claims lifecycle and all processes that affect claims payment to support the business.
• Writes requirements for business review documents (BRDs)/functional requirements documents (FRDs) independently.
• Suggests schema/solutions; collaborates with technical resources to determine optimal solutioning.
• 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 for the configuration team.
• Participates in and/or leads configuration project meetings.
• Manages complex configuration oversight 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 for other configuration team members as needed.
• Provides training and support to new and existing configuration oversight team members; ensures team members receive training and support related to configuration 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.
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: 2036309
Job Category: Operations
Posting Date: 2026-03-19T20:42:10 00:00
Job Schedule: Full time
