JOB DESCRIPTION
Job Summary
Responsible for accurate and timely implementation and maintenance of critical information on claims databases. Maintains critical information on claims databases. Synchronizes data among operational and claims systems and application of business rules as they apply to each database. Validate and audit data to be housed on databases and ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements. Lead and participate in audit initiatives, develop quality control framework, and collaborate cross-functionally to drive continuous improvement in configuration practices and outcomes
KNOWLEDGE/SKILLS/ABILITIES
Trains staff on configuration functionality, enhancements, and updates.
Works with internal and external stakeholders to understand business objectives and processes associated with the enterprise.
Problem solves with Health Plans and Corporate to ensure all end-to-end business requirements have been documented.
Creates management reporting tools to enhance communication on configurations updates and initiatives.
Negotiates expected completion dates with Health Plans.
Lead audits of claims and QNXT configuration to ensure accuracy, completeness, and compliance with internal policies and external regulations.
Develop and maintain audit checklists, quality metrics, and reporting tools.
Identify configuration errors and root causes through analysis ; recommend corrective actions and process improvements.
Develop and implement quality control procedures and best practices for configuration management.
Monitor performance indicators and trends to proactively address quality issues.
Maintain detailed documentation of audit findings, configuration changes, and quality metrics.
Prepare and present audit reports to leadership and stakeholders.
JOB QUALIFICATIONS
Required Education
- Bachelor's Degree or equivalent combination of education and experience
Required Experience
- Deep understanding of QNXT and/or NetworX Pricer configuration modules (Benefits, Provider Contracts, Pricing, Claims Adjudication).
Preferred Education
- Graduate Degree or equivalent experience
Preferred Experience
Strong business writing skills proficient user of Microsoft Products including Word, Excel, Outlooks, Teams, SharePoint, PowerPoint, and Visio
Advanced knowledge of Excel
SQL knowledge
Coding certification
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.
Pay Range: $77,969 - $155,508 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.