Claims Configuration)

Molina Healthcare•Long Beach, CA

32d

About The Position

This role is responsible for the accurate and timely auditing of critical information on claims databases. The Lead Analyst will maintain critical auditing and outcome information, synchronize data among operational and claims systems, and ensure the application of business rules as they apply to each database. This position validates the 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. The Lead Analyst is also responsible for work load assignment to auditors, training and coaching new employees, providing clear and concise results and comments to leaders about focal and random audits across all states, monitoring and controlling workflow, and ensuring 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

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.
Research and review 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 maintain 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 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.