JOB DESCRIPTION

Job Summary

Performs research and analysis of complex healthcare claims data, pharmacy data, and contract data regarding network utilization and cost containment information. Evaluates, writes, and presents healthcare utilization and cost containment reports and makes recommendations based on relevant findings. This position is responsible for proactively identifying claim issues, resolving disputes, and coordinating solutions while overseeing and managing the activities of assigned providers from initiation to completion of the program. This role contributes to the strategic direction and organization of health plan initiatives, facilitating the successful implementation of provider engagement programs.

Duties and Responsibilities (List all essential duties and responsibilities in order of importance)

• Analyze claims from compliance against contracts, billing, and processing guidelines
• Analyze data sets and trends for anomalies, outliers, trend changes, and opportunities to recommend policy changes
• Assist with research, development and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations.
• Responsible for timely completion of projects, including timeline development and maintenance, and coordination of activities and data collection with requesting internal departments or external requestors.
• Initiate in-depth analysis of the suspect/problem areas and suggest a corrective action plan
• Demonstrate Healthcare experience in Quantifying, Measuring and Analyzing Financial and Utilization Metrics of Healthcare.
• Collaborates with internal departments to determine root cause and analytical approach to payment discrepancies.
• Apply investigative skills and analytical methods to look behind the numbers, assess business impacts, and make recommendations through use of healthcare analytics, predictive modleing, etc.
• Interact with various departments including; IT, Contracting, Corporate Services, Claims, Utilization Management and Payment Integrity to understand claim related policies and payment processes, member benefits, contracts and State requirements
• Responsible for documenting policies and procedures related to concept approvals
• Participate in and support the development of strategies to meet the business needs
• Implement and use software and systems to support the department’s goals.
• Other duties as assigned

State Plan / Department Specific Duties and Responsibilities (List all essential duties other than those listed above in order of importance)

• Ability to practice Service Excellence (Molina Kentucky)

Knowledge, Skills and Abilities ( List all knowledge, skills and abilities that are necessary to perform the job satisfactorily)
•    Ability to manage various sources of information and large data sets including pharmacy, claims and encounter data
•    Proficiency in compiling data, creating reports and presenting information, including knowledge of Crystal Reports (or similar reporting tool), SQL query, MS Access and MS Excel
•    Ability to combine clinical and financial data
•    Demonstrated ability to meet established deadlines
•    Ability to function independently and manage multiple projects 
•    Ability to develop scenario analysis using different approaches
•    Ability to present ideas and information concisely to varied audiences
•    Proficiency with PC-based systems, and the ability to learn other systems through knowledge of MS Excel and Access
•    Excellent verbal and written communication skills
•    Ability to quickly assimilate knowledge of processes and systems to develop and deliver necessary training to departmental staff and internal customers
•    Ability to work in a deadline driven department

JOB QUALIFICATIONS

Required Education:  
Bachelor’s Degree; or combination of relevant education and experience

Required Experience:      
4-6 years experience in a Managed Care Environment

Preferred Education:
Bachelor’s Degree in Math, Finance, Business or IS

Preferred Experience:
•    Multiple data systems and models
•    Analysis and Forecasting of trends in medical costs to provide anlytic support for various departments
•    Complex database and data management responsibilities 
•    Claims processing background
•    Basic knowledge of SQL  
Preferred Licensure/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: $63,133 - $129,589.63 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.