Specialist, Configuration Oversight

Molina Healthcare•Long Beach, CA

About The Position

Provides support for configuration oversight activities, including vendor, focal, and audit-the-auditor audits. Reviews documentation to verify claims information accuracy and adherence to business and system requirements related to contracting, network management, credentialing, prior authorizations, fee schedules, and other requirements affecting claim accuracy. Provides counsel related to coverage amounts and benefit interpretation, and communicates clear, concise audit results and commentary in alignment with audit standards. Contributes to compliance, regulatory oversight, and monitoring to support improvements in functional areas.

Requirements

At least 2 years of experience as an auditor in a health care operations setting, or an equivalent combination of relevant education and experience.
Experience using a claims processing system.
Experience verifying documentation related to updates or changes within a claims processing system.
Flexibility to meet changing business requirements and commitment to high-quality, timely delivery.
Attention to detail.
Effective verbal and written communication skills.
Proficiency with Microsoft Office, including Excel, and applicable software programs.

Nice To Haves

Experience in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs.
Intermediate to advanced Microsoft Excel skills.

Responsibilities

Review documentation for updates or changes to member enrollment, provider contracts, provider demographic information, and claim processing guidelines, and evaluate whether those changes were accurately applied in the appropriate core claims processing system modules.
Conduct focal audits of samples of processed transactions affected by updates or changes, verifying that outcomes align with the original documentation.
Audit vendor audits and verify that published outcomes align with documentation and that relevant sources of truth are assessed appropriately.
Document and assess focal audit results.
Research and track unresolved errors identified through daily transactional audits, and communicate with core operations business partners to support resolution within 30 days of error issuance.
Evaluate claims adjudication using standard principles and state-specific policies and regulations to identify incorrect coding, abuse, fraudulent billing, waste, overpayments, and processing errors.
Prepare, track, and provide audit findings reports according to designated timelines.
Present audit findings and recommend improvements to leadership based on audit results.
Manage fluctuating work volumes and prioritize work to meet deadlines and the needs of the configuration department and user community.