JOB DESCRIPTION

Job Summary

Job Summary

Responsible for oversight, production, and resolution of Health Plan Payment Integrity (PI) recovery concepts. Execute and monitor Health Plan Scorable Action Items (SAIS) to ensure performance and quality levels exist in PI Business products and processes. Establishes procedures and techniques to achieve operational goals. Manages inventory and works in collaboration with PI Team to ensure Health Plan SAI targets are met. 

With direction from the Operations Leader, supports implementation and execution of department initiatives that would include one or all of the following PI areas: 

• Overpayment Recovery
• Post Payment Datamining
• Pre-pay Editing for correct coding and medical payment policies. 
• Claim Payment and Adjustment Analysis projects.
• Prioritizes recovery processing, offset reconciliation, refund posting and reconciliation, supports provider dispute resolution, 
• Supports claim referrals and Health Plan special projects.

Responsible for leading Health Plan Meetings when applicable and for creating executive summaries to gain input and feedback from Health Plan Leadership on SAI concepts.

Evaluates analytical findings to ensure accurate interpretation of meaningful data mining results.

Assist in identification of claim payment strategy improvement initiatives to resolve claim payment issues and to support ideation of PI SAIs

Knowledge/Skills/Abilities

• Expertise in claims processing to facilitate claim payment issue resolution, troubleshooting payment/adjustment errors, and quality controls. 
• Expertise in claim coding and state/CMS regulations
• Health Plan root cause analysis specialist, used to identify rework trending to improve overall provider experience.
• 
  Great communication skills to respond to the Payment Integrity Team and Provider inquiries. Understands when to escalate issues for resolution where appropriate.
• Manages SAI inventory and prioritizes work. Ability to analyze complex data driven reports and develop actionable insights for resolution, and management reporting.
• Assists and executes tasks and projects to ensure CMS and State regulatory requirements are met for Pre-pay Edits, Overpayment Recovery which improves encounter submissions, reduces G&A costs, and continues to drive positive operational and financial outcomes for all PI solutions.
• Ability to collaborate with SME throughout the organization to achieve desired results.
• Preferred Certified Coding Specialist

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: $69,779 - $136,069 / 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.