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Analyst, Claims and Configuration
5 months ago
Job Description
The focus of this position will be research and root cause analysis of claims / config issues with direct provider interaction and collaboration with our provider relations team. Additionally, the role will help with overpayment recovery, claims payment and adjustment projects, and reviewing proposed SAI concepts from PI and provide guidance with the help from the Operations leader provide approvals/denials for proposed concepts.
Job Summary
Responsible for comprehensive end to end claim audits. This includes; administering audits related to accurate and timely implementation and maintenance of critical information on all claims and provider databases, validate data housed on databases and ensure adherence to business and system requirements of customers as it pertains to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other business requirements critical to claim accuracy. Maintain audit records, and provide counsel regarding coverage amount and benefit interpretation within the audit process. Monitors and controls backlog and workflow of audits. Ensures that audits are completed in a timely fashion and in accordance with audit standards.
Job Duties
Analyze and interpret data to determine appropriate configuration.
Accurately interprets specific state and/or federal benefits, contracts as well as additional business requirements and converting these terms to configuration parameters.
Validates coding, updating and maintaining benefit plans, provider contracts, fee schedules and various system tables through the user interface.
Works with fluctuating volumes of work and is able to prioritize work to meet deadlines and needs of department.
Reviews documentation regarding updates/changes to member enrollment, provider contract, provider demographic information, claim processing guidelines and/or system configuration requirements. Evaluates the accuracy of these updates/changes as applied to the appropriate modules within the core claims processing system (QNXT).
Conducts high dollar, random and focal audits on samples of processed transactions. Determines that all outcomes are aligned to the original documentation and allow appropriate processing.
Clearly documents the audit results and makes recommendations as necessary.
Researches and tracks the status of unresolved errors issued on daily transactional audits and communicates with Core Operations Functional Business Partners to ensure resolution within 30 days of error issuance.
Helps to evaluate the adjudication of claims using standard principles and state specific policies and regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims.
Prepares, tracks, and provides audit findings reports according to designated timelines
Presents audit findings and makes recommendations to management for improvements based on audit results.
Job Qualifications
**REQUIRED EDUCATION**:
Associate’s Degree or equivalent combination of education and experience
**REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES**:
2+ years of comprehensive end to end claim audits
Knowledge of validating and confirming information related to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other business requirements
Knowledge of verifying documentation related to updates/changes within claims processing system.
Experience using claims processing system (QNXT).
Experience in SQL, PowerBI is required and Salesforce is preferred.
Working experience with CMS guideline would be preferred.
**PREFERRED EDUCATION**:
Bachelor’s Degree or equivalent combination of education and experience
**PREFERRED EXPERIENCE**:
3+ years of experience
**PHYSICAL DEMANDS**:
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only mínimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
**Pay Range**: $49,430.25 - $107,098.87 / ANNUAL
- Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
