Jobs at Molina Healthcare Inc.

Analyze, clean, and validate complex healthcare data; develop statistical, machine learning, and AI models; implement agentic workflows, RAG solutions, and model fine-tuning; deploy and monitor models in production; collaborate with technical and business teams; conduct research; and document and communicate findings.

Analyzes and interprets regulatory and functional requirements for coverage, reimbursement, and processing systems. Maintains requirement documentation, monitors policy updates, coordinates stakeholders and governance committees, investigates compliance-related root causes, and communicates impacts to health plans and operational leadership. Supports requirement alignment, traceability, issue resolution, and benefit planning across multiple states and business lines in a remote environment.

Supports health plan finance through monthly close, budgeting, forecasting, regulatory reporting, financial modeling, variance analysis, and ad hoc leadership reporting. Evaluates financial information, investigates discrepancies, develops finance policies and procedures, and recommends actions related to investments, operations, product development, and regulatory initiatives. Collaborates with technical and non-technical stakeholders and manages multiple deadlines.

Manage claims program governance, policies, workflows, controls, budgets and vendor practices. Drive portfolio/initiative change, create requirement/test/training documentation, track metrics, coordinate governance meetings, and recommend program enhancements to improve adoption and value realization.

Validate and maintain provider demographic, affiliation, and fee schedule data in health plan systems; accurately enter and audit provider records for quality and financial accuracy; review incoming provider information; assist with configuration issue resolution and provider network administration projects; provide documented feedback and customer support.

Investigate and resolve member and provider appeals, grievances, and claims disputes per CMS and Molina guidelines. Research records and billing, apply benefits and contract language, prepare correspondence and appeal summaries, document findings, and meet departmental production and regulatory timelines.

Lead risk and quality performance initiatives by managing data collection, analytics, and reporting for HEDIS, CAHPS, SDOH, and risk adjustment. Oversee data ingestion, ensure regulatory and HEDIS audit compliance, communicate status to stakeholders, recommend improvements, and collaborate cross-functionally to close care gaps and optimize program documentation and delivery.

Conduct clinical audits across utilization management, care management, behavioral health, and related teams to ensure compliance with NCQA, CMS, HIPAA and state/federal guidelines. Identify care gaps, assess clinical decision-making, report outcomes, recommend retraining, maintain audit records, and support training development to improve quality and member outcomes.

Researches and analyzes medical claims to ensure regulatory compliance, identify root causes of processing errors, lead complex claims projects, develop and track remediation plans, coordinate cross-functional stakeholders, recommend SOP updates, and monitor claims reprocessing to resolution.

Conducts preliminary and end-to-end investigations into healthcare fraud, waste, and abuse (FWA), including data analysis, medical record and coding reviews, interviews, on-site inspections, audit reporting, referrals to regulators/law enforcement, provider education, and coordination with internal stakeholders to determine overpayments and ensure regulatory compliance.

Manage process improvement, organizational change, and project delivery including estimating, scheduling, costing, planning, and risk/issue management. Develop detailed project and communication plans, define roles, and use project-specific software. Support intermediate to large-scale projects with cross-functional teams and present alternatives to overcome obstacles.

Manage MMISR program activities including configuration, testing, workflows, governance, vendor practices, budgets, performance tracking, and stakeholder coordination. Produce requirements, test plans, training materials, and recurring reports while driving process improvements and adoption of program guardrails.

Analyze and interpret regulatory and functional requirements related to coverage, reimbursement, and processing. Develop and maintain requirement documents, coordinate with stakeholders and governance committees, conduct root-cause analysis, communicate interpretations to product and operations teams, and support compliance and benefit planning activities.

Designs and develops reporting solutions for HEDIS auditing, rate tracking, and performance metric tracking. Collects, validates, analyzes managed care data (claims, pharmacy, lab), builds QA and medical record review reports, supports predictive intervention analytics, conducts root-cause analysis, and communicates findings to stakeholders to drive quality improvement.

Analyze healthcare and operational datasets to create, validate, and maintain reports and dashboards using SQL, Excel, and BI tools. Support utilization, cost containment, regulatory reporting, and ad hoc analyses. Collaborate with stakeholders to define requirements, document workflows, and deliver actionable recommendations.

Lead and maintain program governance: document policies, workflows, controls, and playbooks; manage budgets and performance metrics; coordinate governance meetings; support portfolio/change management; produce requirements, test plans, training, and scheduled reports.

Provide legal support on corporate governance, entity management, intercompany agreements, regulatory audit responses, and oversee the corporate paralegal team. Partner with compliance, tax, and business stakeholders to improve governance processes and legal operations across subsidiaries.

Lead a team managing provider data management (PDM) processes, establish SOPs and policies, collaborate cross-functionally, design provider data programs, respond to regulatory/audit issues, implement corrective actions, and drive continuous improvement using automation and AI to optimize provider information accuracy across claims and provider systems.

Lead a team overseeing operational controls, audits, compliance, and corrective actions across corporate operations. Liaise with regulators and auditors, manage CAPs, ensure regulatory alignment across states, support SIU and legal, and drive operational performance and improvement. Hire, train, and manage staff and may oversee financial/performance results for select operational units.

Provide senior support for government contracts for Medicaid, Medicare and Marketplace programs. Review and prepare regulatory filings, ensure contractual and regulatory compliance of plan materials, coordinate with state agencies and internal teams, maintain documentation archives, and conduct evidence reviews and audits.