JOB DESCRIPTION Job Summary
Provides analyst support for configuration oversight activities. 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 of customers as it pertains to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other business requirements critical to claim 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.
This role will focus on auditing claims on transplants.
Essential Job Duties
• Analyzes and interprets data to determine accurate/appropriate configuration.
• Accurately interprets state and/or federal benefits, contracts, and business requirements and converts these terms to configuration parameters.
• Validates coding, updates and maintains benefit plans, provider contracts, fee schedules and various system tables through the user interface.
• Applies previous experience and knowledge to verify accuracy of updates to claim/encounter and/or system updates as necessary.
• Reviews documentation regarding updates/changes to member enrollment, provider contracts, provider demographic information, claim processing guidelines and/or system configuration requirements; evaluates the accuracy of these updates/changes as applied to appropriate modules within the core claims processing system.
• Conducts high-dollar, random and focal audits on samples of processed transactions; ensures outcomes are aligned to original documentation and allows for appropriate processing.
• Clearly documents audit results and makes recommendations as necessary.
• Researches and tracks the status of unresolved errors issued on daily transactional audits, and communicates with core operations functional business partners to ensure resolution within 30 days of error issuance.
• Helps evaluate the adjudication of claims using standard principles and state specific policies and regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims.
• Prepares, tracks, and provides audit findings reports according to designated timelines.
• Presents configuration audit findings and makes recommendations to leadership for improvements based on audit results.
• Manages fluctuating volumes of work and prioritizes work to meet deadlines and needs of the configuration department and user community.
Required Qualifications
• At least 2 years of claims auditing experience within a health care operations setting, or equivalent combination of relevant education and experience.
• Experience/understanding of claims processes and claims auditing.
• Experience verifying documentation related to updates/changes within claims processing system.
• Experience validating and confirming information related to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other business requirements.
• Analytical and critical-thinking skills.
• Flexibility to meet changing business requirements, and commitment to high-quality/on-time delivery
• Attention to detail.
• Effective verbal and written communication skills.
• Microsoft Office suite proficiency, including Excel abilities (VLOOKUP/Pivot Tables, etc.), and applicable software programs proficiency.
Preferred Qualifications
• Experience in a managed care organization supporting Medicaid, Medicare and/or Marketplace programs.
• Intermediate to advanced Microsoft Excel skills.
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
Skills Required
- At least 2 years of claims auditing experience within a health care operations setting, or equivalent combination of relevant education and experience.
- Experience/understanding of claims processes and claims auditing.
- Experience verifying documentation related to updates/changes within claims processing system.
- Experience validating and confirming information related to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other business requirements.
- Analytical and critical-thinking skills.
- Flexibility to meet changing business requirements, and commitment to high-quality/on-time delivery.
- Attention to detail.
- Effective verbal and written communication skills.
- Microsoft Office suite proficiency, including Excel abilities (VLOOKUP/Pivot Tables, etc.), and applicable software programs proficiency.
- Experience in a managed care organization supporting Medicaid, Medicare and/or Marketplace programs.
- Intermediate to advanced Microsoft Excel skills.
What We Do
Molina Healthcare Inc. is dedicated to delivering effective, reliable, and affordable health care to those who need it most. The company focuses on improving the health and well-being of its members and positively impacting the communities it serves. Recognized as a leader in the health insurance category, it provides essential healthcare services to ensure accessible and quality care for its members.
