Lead Analyst, Claims COB Audit

Molina Healthcare•Long Beach, CA

About The Position

Provides lead level support for COB-specific claim pricing audits. 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. 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.

Requirements

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.

Nice To Haves

Experience mentoring and/or training peers.
Bachelor's degree

Responsibilities

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 reports and automated configuration processes/solutions.
Leads peer review processes.
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.
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.
Participates in and/or leads project meetings.
Manages complex 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 as needed.
Provides training and support to new and existing team members; ensures team members receive training and support related to functionality, enhancements and updates.
Manages fluctuating volumes of work, and prioritizes work to meet deadlines and needs of the configuration department and user community.