Job Description

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

• 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).
• Strong knowledge of using Microsoft applications to include; Excel, Word, Outlook, PowerPoint and Teams

PREFERRED EDUCATION:

Bachelor’s Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE:

3+ years of experience

• Comprehensive claims processing experience (QNXT) as Examiner or Adjuster
• Experience independently reviewing and processing simple to moderately complex High dollar claims and knowledge of all claim types of reimbursements not limited to payment methodologies such Stoploss, DRG, APC, RBRVS, FFS applicable for HD Inpatient, Outpatient and Professional claims.
• Knowledge of relevant CMS rules and/or State regulations with different line of business as: Medicare, Medicaid, Marketplace, Dual coverages/COB.
• 2+ years of comprehensive claim audits as preference
• Knowledge of validating and confirming information related to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other business requirements
• Proficient in claims software and audit tools not limited to QNXT, PEGA, NetworX pricer, Webstrat, Encoder Pro and Claims Viewer.
• Strong analytical and problem-solving abilities, able to understand, interpret and read out through SOPs, Job Aid guidelines.
• Knowledge of verifying documentation related to updates/changes within claims processing system .
• Strong knowledge of using Microsoft applications to include Excel, Word, Outlook, PowerPoint and Teams
• The candidate must have the ability to prioritize multiple tasks, meet deadlines and provide excellent customer service skills. 

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.

#PJCorp

Pay Range: $77,969 - $128,519 / 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.