Analyst, Claims and Configuration

3 weeks ago

Long Beach, United States Molina Healthcare Full time
Job Description

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

In this role, the candidate would be working with internal and external clients. Constant Provider interaction will be required.
  • 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.
  • Apply previous experience and knowledge to verify accuracy of updates to claim/encounter and/or system update(s) as necessary.
  • 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.
  • Strong knowledge of using Microsoft applications to include; Excel, Word, Outlook, PowerPoint and Teams.
  • 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 minimal 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.

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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