Manager, Configuration - Product Owner/Custom Solutions

Molina Healthcare•Long Beach, CA

About The Position

Leads and manages a team responsible for configuration activities, including the accurate and timely implementation and maintenance of critical information on claims databases. This role involves validating data stored on databases and ensuring adherence to health plan business and system requirements related to contracting, benefits, prior authorizations, fee schedules, and other business needs.

Requirements

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 an 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 a 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 proficiency in applicable software programs.

Nice To Haves

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.

Responsibilities

Manages the configuration team and is accountable for team performance, including meeting or exceeding established performance targets based on health plan, federal, or state requirements.
Serves as the primary liaison with various functional areas and stakeholders (e.g., utilization management, claims, configuration, provider network, health plan leadership) to understand workflows and gather documentation for audits.
Leads and organizes audit submissions and interacts with auditors.
Develops policies and procedures for the end-to-end audit process to ensure consistency and compliance.
Supports the review of operational policies, procedures, guidelines, and job aids to ensure compliance with company and government regulations.
Identifies risks related to operational oversight processes, recommends mitigation solutions, and reports to leadership.
Participates in and contributes to the development of configuration-related strategies to meet business needs.
Conducts and documents monthly operational meetings with health plans.
Provides guidance to the team regarding the interpretation of specific state and/or federal benefits, benefit and provider contracts, and business requirements (e.g., coding, system tables, fee schedules), and converts terms to configuration parameters.
Develops and coaches the direct configuration team, promoting professional growth and development.
Maintains awareness of current laws, regulations, and statutes for assigned operational areas audited by the team.
Proactively works with leadership on operational effectiveness to ensure compliance.
Performs analysis and reviews to ensure configuration performance targets are met.
Plans 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.
Acts as a technical expert in handling complaints and escalated issues from internal customers.
Leads performance improvement activities for the configuration function.
Manages fluctuating work volumes and prioritizes work to meet deadlines and the needs of the configuration department and user community.
Hires, trains, develops, and manages the team, demonstrating accountability for team performance and achievement of configuration/department-specific goals.