JOB DESCRIPTION Job Summary
Leads and manages team responsible for configuration activities including accurate and timely implementation and maintenance of critical information on claims databases, validation of data stored on databases, and adherence to health plan business and system requirements as it pertains to contracting, benefits, prior authorizations, fee schedules and other business requirements.
Essential Job Duties
- Manages configuration team, and demonstrates accountability for team performance - including meeting or exceeding established performance targets; targets may be based upon specific health plan requirements, and/or federal/state requirements.
• Represents as primary liaison with various functional areas/stakeholders (i.e. utilization management, claims, configuration, provider network, health plan leadership, etc.) to seek understanding of workflows and obtain required documentation for applicable audits.
• Leads and organizes audit submissions and interacts with auditors as applicable.
• Develops policies and procedures for end-to-end audit process to ensure consistency/compliance.
• Supports review of operational policies, procedures, guidelines, and job aids to ensure compliance with company and government regulations.
• Identifies risks related to operational oversight processes, provides recommendation for mitigation solutions, and reports to leadership.
• Participates in and contributes to the development of configuration related strategies to meet business needs.
• Conducts and documents operational meetings with health plans on a monthly basis.
• Provides guidance to team regarding interpretation of specific state and/or federal benefits, benefit and provider contracts, in addition to business requirements (i.e. coding, system tables, fee schedules, etc.), and converts terms to configuration parameters.
• Develops and coaches direct configuration team - promoting professional growth and development.
• Maintains awareness of current laws, regulations, statutes, etc. for assigned area(s) of operations audited by team.
• Proactively works with leadership on operational effectiveness to ensure compliance.
• Performs analysis and reviews to ensure configuration performance targets are met.
• Plans for daily priorities, and responds to new priorities and opportunities assigned by leadership.
• Assists with compiling and submitting daily, weekly and monthly departmental reports to leadership.
• Represents as a technical expert in handling complaints and other escalated issues from internal customers.
• Leads performance improvement activities for the configuration function.
• Manages fluctuating volumes of work and prioritizes work to meet deadlines and needs of the configuration department and user community.
• Hires, trains, develops and manages team; demonstrates accountability for team performance and achievement of configuration/department-specific goals.
Required Qualifications
- At least 7 years of configuration oversight, claims, auditing, and/or health care operations experience in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or equivalent combination of relevant education and experience.
• At least 1 year of management/leadership experience.
• Advanced understanding of claims processes.
• Advanced ability to identify and troubleshoot claim discrepancies by utilizing benefit and provider contracts, regulatory requirements and various claims related resources.
• Strong analytical, critical-thinking, and problem-solving skills.
• Strong multitasking ability, and decision-making skills.
• Flexibility to meet changing business requirements, and strong commitment to high-quality/on-time delivery.
• Ability to work cross-collaboratively in a highly matrixed organization.
• 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
• Certified Professional Coder (CPC).
- Experience leading analysis and operational teams in a managed care setting.
• Experience collaborating with various levels of leadership in a highly matrixed organization.
• Deep claims processing, configuration and queries experience.
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To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
offers a competitive benefits and compensation package. is an Equal Opportunity Employer (EOE) M/F/D/V
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