Supervisor, Oversight (Payment Integrity Claims Audit)

Molina Healthcare•Long Beach, CA

About The Position

Leads and supervises a team responsible for configuration oversight activities. This includes the accurate and timely implementation and maintenance of critical information on claims databases, validation of data stored on databases, and adherence to health plan business and system requirements as it pertains to auditing of contracting, benefits, prior authorizations, fee schedules, and other business requirements.

Requirements

At least 6 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 equivalent combination of relevant education and 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 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 applicable software programs proficiency.
Must have experience working with high $ claims processing.

Nice To Haves

Management/leadership experience.

Responsibilities

Supervises the configuration oversight (Claims Audit) team, demonstrating accountability for team performance, including meeting or exceeding established performance targets based on health plan, federal, or state requirements.
Oversees end-to-end audits, internal operating controls, and processes/practices for operational areas such as claims, configuration, and provider operations.
Ensures timely completion of audits and compliance with audit standards.
Compiles and shares audit outcomes with operations functional areas for review and action, ensuring findings are corrected within appropriate time frames and in accordance with cost control/regulatory standards.
Serves as the primary liaison with various functional areas/stakeholders (e.g., utilization management, claims, configuration, provider network, health plan leadership) to understand workflows and obtain required documentation for audits.
Demonstrates accountability for identifying regulatory compliance issues within various operations functions to validate and mitigate risks, and ensure improvement activities are in progress.
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, provides recommendations for mitigation solutions, and reports accordingly to leadership.
Participates in and contributes to the development of strategies to meet business needs.
Conducts and documents operational meetings with business partners (vendors, health plans, claim operations, etc.) on a monthly basis.
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.
Maintains awareness of current laws, regulations, statutes, etc., for assigned areas of operations audited by the team.
Proactively collaborates with leadership on operational effectiveness to ensure compliance.
Performs analysis and reviews to ensure configuration performance targets are met.
Effectively plans for daily priorities and responds to new priorities and opportunities assigned by leadership.
Assists with compiling and submitting daily, weekly, and monthly departmental configuration reports to leadership.
Serves as a technical expert in handling complaints and other escalated issues from internal customers.
Leads performance improvement activities for the configuration oversight 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.