Supervisor, Oversight (Payment Integrity Claims Audit)

Molina Healthcare•Long Beach, CA

About The Position

Leads and supervises a team responsible for configuration Oversight activities, including 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 configuration Oversight (Claims Audit) team, and demonstrates accountability for team performance - including meeting or exceeding established performance targets; targets may be based upon specific health plan requirements, and/or federal/state requirements.
Oversees end-to-end audits, internal operating controls and processes/practices for operational areas including claims, configuration, provider operations, etc.
Ensures completion of timely audits and compliance with audit standards.
Compiles and shares audit outcomes with operations functional areas for review and action, and ensures that findings are corrected within appropriate time frames and in accordance with cost control/regulatory standards.
Represents as primary liaison with various functional areas/stakeholders (i.e. utilization management, claims, configuration, provider network, health plan leadership, etc.) to seek understanding of workflows and obtain required documentation for applicable audits.
Demonstrates accountability for identifying regulatory compliance issues within various operations functions areas to validate and mitigate risks, and ensure that improvement activities in functional support areas are in progress.
Leads and organizes audit submissions and interacts with auditors as applicable.
Develops policies and procedures for end-to-end audit process to ensure consistency/compliance.
Supports 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 recommendation 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 team regarding interpretation of specific state and/or federal benefits, benefit and provider contracts, and business requirements (i.e. coding, system tables, fee schedules, etc.), and converts terms to configuration parameters.
Maintains awareness of current laws, regulations, statutes, etc. for assigned area(s) of operations audited by 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.
Represents as a technical expert in handling complaints and other escalated issues from internal customers.
Leads performance improvement activities for configuration oversight function.
Manages fluctuating volumes of work and prioritizes work to meet deadlines and needs of the configuration department and user community.
Hires, trains, develops and manages team; demonstrates accountability for team performance and achievement of configuration/department-specific goals.