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Job Description

Job Summary

Serves as claims subject matter expert. Assist the business teams with reviewing claims to ensure regulatory requirements are appropriately applied. Manages and leads major claims projects of considerable complexity and volume that may be initiated through provider inquiries or complaints, legal requests, or identified internally by Molina. Identifies the root cause of processing errors through research and analysis, coordinates and engages with appropriate departments, develops and tracks remediation plans, and monitors claims reprocessing through resolution. Interprets and presents in-depth analysis of findings and results to leadership and respective operations teams. Responsible for ensuring the projects are completed accurately and timely.

Job Duties

• Uses analytical skills to conducts research and analysis for issues, requests, and inquiries of high priority claims projects

• Assists with reducing re-work by identifying and remediating claims processing issues

• Locate and interpret regulatory and contractual requirements

• Tailors existing reports or available data to meet the needs of the claims project

• Evaluates claims using standard principles and applicable state specific policies and regulations to identify claims processing errors

• Applies claims processing and technical knowledge to appropriately define a path for short/long term systematic or operational fixes

• Helps to improve overall claims performance to ensure claims are processed accurately and timely

• Identifies claims requiring reprocessing or re-adjudication in a timely manner to ensure compliance

• Works closely with external departments to define claims requirements

• Recommends updates to Claims SOP’s and Job Aid’s to increase the quality and efficiency of claims processing

• Fields claims questions from Molina Operations teams

• Interprets, communicates, and presents, clear in-depth analysis of claims research results, root cause analysis, remediation plans and fixes, overall progress, and status of impacted claims

• Provides excellent customer services to our internal operations teams concerning claims projects

• Appropriately convey information and tailor communication based on the targeted audience

• Provides sufficient claims information to our internal operations teams that must communicate externally to provider or members

• Able to work in a project team setting while also able to complete tasks individually within the provided timeline or as needed, accelerated timeline to minimize provider/member impacts and/or maintain compliance

• Manages work assignments and prioritization appropriately

• Other duties as assigned.

Job Qualifications

REQUIRED EDUCATION:

Associate’s degree or equivalent combination of education and experience

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

• 1-3 years claims analysis experience

• 5+ years medical claims processing experience across multiple states, markets, and claim types

• Demonstrates familiarity in a variety of concepts, practices, and procedures applicable to job-related subject areas

• Knowledge and experience using Excel

PREFERRED EDUCATION:

Bachelor's Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE:

• 1-3 years claims analysis

• 6+ years medical claims processing experience

• Project management

• Expert in Excel and PowerPoint

PHYSICAL DEMANDS:

Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

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Pay Range: $17.85 - $38.69 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.