Claims Configuration)

Molina Healthcare•Long Beach, CA

31d

About The Position

Responsible for accurate and timely auditing of critical information on claims databases. Maintains critical auditing and outcome information. Synchronizes data among operational and claims systems and application of business rules as they apply to each database. Validate accuracy of configuration and ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements. Responsible for work load assignment to auditors. Train and coach new employees. Provide clear and concise results and comments to leaders about focal and random audits across all states. Monitors and controls workflow. Ensures that audits are conducted in a timely fashion and in accordance with unit standards.

Requirements

Bachelor’s Degree or equivalent combination of education and experience
5-6 Years of experience
Understanding of QNXT, AutoQ, and MCG functionality and schema
Ability to write Requirements for BRDs/FRDs and Reports without needing mentoring
Ability to suggest schema/solution and work with technical resources to determine the best solution
Ability to manage complex projects from requirements to deployment, including work assignment, prioritization, issue triage etc.
Ability to research complex issues
Ability to act as a team lead, assigning and prioritizing work for other team members
Ability to train audit staff on configuration functionality, enhancements and updates
Ability to accurately interpret end to end business requirements and confirm outcomes meet specific state/federal requirements
Ability to create management reporting tools
Ability to write complex ad-hoc reports
Ability to interpret and validate accuracy of complex MRDT and other configuration update scripts
Ability to interpret and validate accuracy of complex reports and automated configuration processes/solutions
Ability to validate accuracy of new complex configuration processes/solutions
Ability to verify accuracy of MRDT, fee schedule, premium, AutoQ, and other file load packages
Ability to interpret complex business problems and technical issues
Ability to effectively communicate audit findings and/or outcomes through review meetings, written communications, and workflow diagrams
Ability to gain a deep understanding of Molina claims life cycle and all processes that affect claims payment
Ability to develop and maintain standards and best practices for the team
Ability to mentor junior auditors
Ability to participate in or lead project meetings
Responsible for accurate and timely auditing of critical information on claims databases
Maintains critical auditing and outcome information
Synchronizes data among operational and claims systems and application of business rules as they apply to each database
Validates accuracy of configuration and ensures adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements
Responsible for work load assignment to auditors
Trains and coaches new employees
Provides clear and concise results and comments to leaders about focal and random audits across all states
Monitors and controls workflow
Ensures that audits are conducted in a timely fashion and in accordance with unit standards

Nice To Haves

Graduate Degree or equivalent experience
7+ Years of experience

Responsibilities

Trains audit staff on configuration functionality, enhancements and updates.
Accurately interprets end to end business requirements and able to confirm outcomes meet the specific state/federal requirements.
Creates management reporting tools to enhance audit communication on configurations accuracy results and/or audit findings.
Writes complex ad-hoc reports.
Interprets and validates accuracy of complex MRDT and other configuration update scripts.
Assists manager in establishing standards, guidelines, and best practices for the audit team.
Interprets and validates accuracy of complex reports and automated configuration processes/solutions.
Assist manager in establishing peer review standards and methodology.
Leads peer reviews.
Researches and reviews new audit tools and techniques and provide recommendations to management.
Validates accuracy of new complex configuration processes/solutions.
Verifies accuracy of MRDT, fee schedule, premium, AutoQ, and other file load packages.
Interprets complex business problems and technical issues.
Effectively communicates audit findings and/or outcomes through review meetings, written communications, and workflow diagrams.
Helps drive solution to successful implementation by directing technical and business resources during all phases of the software development life cycle.
Gains a deep understanding of Molina claims life cycle and all processes that affect claims payment.
Develops and maintains standards and best practices for the team.
Mentors junior auditors.
Participates in or leads project meetings.
Understands QNXT, AutoQ, and MCG functionality and schema.
Writes Requirements for BRDs/FRDs and Reports without needing mentoring.
Suggests schema/solution.
Works with technical resource to determine best solution.
Manages complex projects from requirements to deployment, including work assignment, prioritization, issue triage etc.
Researches complex issues.
Acts as a team lead, assigning and prioritizing work for other team members as needed.
Responsible for accurate and timely auditing of critical information on claims databases.
Maintains critical auditing and outcome information.
Synchronizes data among operational and claims systems and application of business rules as they apply to each database.
Validate accuracy of configuration and ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements.
Responsible for work load assignment to auditors.
Train and coach new employees.
Provide clear and concise results and comments to leaders about focal and random audits across all states.
Monitors and controls workflow.
Ensures that audits are conducted in a timely fashion and in accordance with unit standards.