Analyst, Configuration Oversight - Claims audit

Job Title

Provides analyst oversight support for payment integrity post payment recovery concepts. Responsible for accurate and timely implementation and maintenance of the payment integrity post pay recovery concepts, validating data housed on databases and ensuring adherence to business and system requirements of Molina health plans as it pertains to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, business coding and billing requirements, and accuracy of payment methodologies critical to claim processing and adjudication accuracy. Facilitates end-to-end claim/concept quality assurance (QA) audits, maintains audit records, provides counsel regarding audit findings and interpretation, monitors and controls backlog and workflow of audits, and ensures that audits are completed in a timely fashion and in accordance with audit standards.

Essential Job Duties

Analyze and interpret claims data, supporting documentation, and payment integrity concept white papers to assess billing accuracy, payment integrity, and compliance with business requirements.

Interpret and apply state and federal regulations, benefit plans, provider contracts, reimbursement methodologies, organizational policies, and coding guidelines to support accurate claims processing and payment outcomes.

Conduct comprehensive quality assurance audits of new and existing payment integrity concepts to validate billing accuracy, reimbursement methodologies, system configuration, claims adjudication outcomes, and concept effectiveness.

Evaluate claims adjudication using applicable coding standards, reimbursement policies, contractual requirements, and regulatory guidance to identify billing inaccuracies, improper payments, overpayments, waste, abuse, fraud indicators, and processing errors.

Ensure audit outcomes align with supporting documentation, regulatory requirements, business rules, and intended concept logic.

Document audit findings, identify root causes, assign appropriate error classifications, and communicate clear recommendations and corrective actions.

Research, track, and facilitate resolution of audit findings, identified defects, and unresolved errors through collaboration with operational and cross-functional business partners.

Develop and recommend process improvements, audit enhancements, and system optimization opportunities to improve payment integrity and operational effectiveness.

Prepare, maintain, and distribute audit reports, findings summaries, metrics, and status updates in accordance with established timelines and reporting requirements.

Present audit findings, trends, risks, and recommendations to leadership and stakeholders to support informed decision-making and continuous improvement initiatives.

Manage audit workloads, competing priorities, and project timelines to ensure timely completion of assignments and adherence to quality and performance standards.

Required Qualifications

At least 5 years of claims auditing experience within a health care operations setting, or equivalent combination of relevant education and experience. Experience/understanding of claims processes and claims auditing. Experience verifying documentation related to updates/changes within claims processing system. Experience validating and confirming information related to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other business requirements. Analytical and critical-thinking skills. Flexibility to meet changing business requirements, and commitment to high-quality/on-time delivery Attention to detail. Effective verbal and written communication skills. Microsoft Office suite proficiency, including Excel abilities (VLOOKUP/Pivot Tables, etc.), and applicable software programs proficiency.

Preferred Qualifications

Experience in a managed care organization supporting Medicaid, Medicare and/or Marketplace programs. Intermediate to advanced Microsoft Excel skills.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V