JOB DESCRIPTION
Job Summary
This position supports Payment Integrity through the research and development of post-pay recovery concepts and claims edits. The role analyzes healthcare claims, medical billing and coding requirements, and reimbursement policies to identify potential overpayment opportunities and translate findings into clearly defined business requirements for technical implementation.
JOB DUTIES
- Researches and develops post-pay Payment Integrity recovery concepts and claims edits by evaluating healthcare claims, reimbursement patterns, medical billing and coding requirements, and applicable regulatory and payer guidance.
- Researches and interprets CMS, NCCI, state Medicaid, Medicare, and other applicable reimbursement and coding requirements to support development of defensible claims-recovery logic.
- Translates identified Payment Integrity opportunities into detailed business requirements, including claim logic, coding criteria, inclusions, exclusions, and supporting documentation for analytic and technical development teams.
KNOWLEDGE/SKILLS/ABILITIES
- Working knowledge of healthcare claims, medical billing, reimbursement methodologies, and coding systems including CPT, HCPCS, ICD-10, revenue codes, modifiers, and claim types.
- Ability to research reimbursement and coding policies and translate policy requirements into actionable claims logic and business requirements.
- Ability to analyze claims data to identify billing patterns, potential overpayments, and opportunities for Payment Integrity recovery concepts.
JOB QUALIFICATIONS
Required Qualifications
- At least 2 years of experience in previous roles in a managed care organization, health insurance or directly adjacent field, or equivalent combination of relevant education and experience.
- Policy/government legislative review knowledge.
- Strong analytical and problem-solving skills.
- Robust knowledge of Office Product Suite including Word, Excel, Outlook and Teams.
- Previous success in a dynamic and autonomous work environment.
Preferred Qualifications
- Experience working with healthcare claims, medical billing/coding, reimbursement, payment integrity, claims auditing, or an equivalent claims-focused function.
- Payment Integrity or post-pay claims recovery experience.
- Experience developing or supporting claims edits, payment policies, recovery concepts, or reimbursement rules.
- Experience with CMS, NCCI, Medicare, Medicaid, and/or state-specific reimbursement guidance.
- Medical coding certification such as CPC, CCS, COC, or equivalent.
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 experience in a managed care organization, health insurance, or directly adjacent field, or equivalent education and experience
- Knowledge of policy and government legislative review
- Strong analytical and problem-solving skills
- Robust knowledge of Microsoft Office products, including Word, Excel, Outlook, and Teams
- Previous success working in a dynamic and autonomous environment
- Experience with healthcare claims, medical billing or coding, reimbursement, payment integrity, claims auditing, or equivalent claims-focused work
- Payment Integrity or post-pay claims recovery experience
- Experience developing or supporting claims edits, payment policies, recovery concepts, or reimbursement rules
- Experience with CMS, NCCI, Medicare, Medicaid, or state-specific reimbursement guidance
- Medical coding certification such as CPC, CCS, COC, or equivalent
Molina Healthcare Inc. Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Molina Healthcare Inc. and has not been reviewed or approved by Molina Healthcare Inc..
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Healthcare Strength — Health coverage is described as solid, including medical, dental, and vision insurance alongside options like HSA/FSA and disability coverage. Benefits are often seen as a meaningful part of the overall package.
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Retirement Support — A 401(k) with employer matching and an ESPP are offered, and the retirement plan is commonly regarded as a plus. These features help round out compensation even when base pay is seen as only acceptable.
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Leave & Time Off Breadth — PTO, paid holidays, and paid parental leave are part of the offering, with time‑off benefits generally viewed favorably. Backup family care and an employee assistance program add practical support.
Molina Healthcare Inc. Insights
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.
