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Auditor, Provider Inquiry/Services

Long Beach, California Job ID 1902328
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Job Description

Job Summary
Molina Health Plan Operations jobs are responsible for the development and administration of our State health plan's operational departments, programs and services, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations.

Provider Inquiry/Services staff are responsible for the submission, research, and resolution of provider inquiries and/or disputes. They respond with the answer to all incoming inquiries and coordinate with other departments within Molina as needed to resolve the provider's issue as well as to try to correct the underlying cause so that the problem is unlikely to happen again. They communicate with Molina providers via e-mail, phone, and written letters, ensuring that resolutions are timely and in compliance with all regulatory requirements.

• Conducts audits of the health plan's Provider Inquiry/Services operations for quality and accuracy, as prescribed by established internal audit policies and procedures and based on an audit schedule for each functional area within the department.
• Work to be audited includes, but is not limited to: PDR and Code edit appeal cases to ensure policy and procedure are followed and the appropriate outcome is generated, outgoing provider correspondence including e-mail and other written communications, will also audit phone staff receiving inbound calls from providers and internal stake holders
• May also interface with and review work performed by the Member Appeals and Grievances team, as needed, including verifying the accuracy of appeal data loading, timely processing, and disposition (e.g., using correct appeal/denial letter).
• Collects audit data, analyzes/interprets results, and prepares written reports of findings to management, on both an aggregate and individual associate performance level. Prepares additional written reports as needed under the direction of the management team.
• Tracks and trends audit results at prescribed frequencies to identify and communicate patterns of non-compliance with established standards and requirements (e.g., with respect to timeliness and accurate categorization and processing of work).
• Coordinates with the management team and department trainer on training and improvement opportunities based on specific results of audits conducted.
• Maintains and protects members' Personal Health Information (PHI) in accordance with HIPAA law.


Job Qualifications

Required Education
Associate's Degree or equivalent combination of education and work experience.
Required Experience
• 4 years of related experience in a managed healthcare setting.
• Experience in customer/member services or prior authorization within a Medicare or Medicaid environment may substitute for up to two years of the minimum required experience.
Required License, Certification, Association
Preferred Education
Bachelor's Degree
Preferred Experience
1+ years in an auditing role
Preferred License, Certification, Association
Certification or licensing in medical terminology or clinical practices is preferred.

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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