Analyst, Configuration Oversight (Claims Auditor)

Job Summary

Responsible for comprehensive contract review and target claims audit review. This includes but not limited to deep dive, contract review and targeted claims audits related to accurate and timely implementations and maintenance of critical information on all claims and provider databases, validate data stored on databases and ensure adherence to business and system requirements of stakeholders as it pertains to provider contracting, network management, credentialling, benefits, prior authorizations, fee schedules, and other business requirements critical to claim accuracy. This contract review provides oversight to ensure that the contracts are configured correctly in QNXT. The Claims are reviewed to ensure the configuration services are correct. Maintain the audit workbook and provide summation regarding the assigned tasks. Manage findings follow up and tracking with stakeholders / requestors.

Ensured the assigned tasks are completed in a timely fashion and in accordance with department standards.

Responsibilities

Conduct comprehensive contract review and targeted claims audits to ensure accurate and timely implementations and maintenance of critical information in claims and provider databases.

Validate data stored in databases and ensure adherence to business and system requirements related to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other requirements critical to claim accuracy.

Ensure contracts are configured correctly in QNXT and that claims are reviewed to verify configuration services.

Maintain the audit workbook and provide summaries of assigned tasks; manage findings, follow-up, and tracking with stakeholders / requestors.

Complete tasks in a timely fashion in accordance with department standards.

Qualifications

REQUIRED EDUCATION :

Associate's Degree or equivalent combination of education and experience

REQUIRED EXPERIENCE / KNOWLEDGE, SKILLS & ABILITIES :

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 claims types of reimbursement including methods such as Stoploss, DRG, APC, RBRVS, FFS for HD Inpatient, Outpatient, and Professional claims.

Knowledge of relevant CMS rules and / or State regulations with lines of business such as Medicare, Medicaid, Marketplace, Dual Coverage / COB.

2+ years of comprehensive end-to-end claim audits as a 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 and software audit tools including but 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 SOPs and job aide guidelines.

Knowledge of verifying documentation related to updates / changes within claims processing systems.

Strong knowledge of using Microsoft applications including Excel, Word, Outlook, PowerPoint and Teams.

The candidate must have the ability to prioritize multiple tasks, meet deadlines and provide excellent customer service skills.

PREFERRED EDUCATION :

Bachelor's Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE :

3+ years of experience

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.

Additional Information

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 : $77,969 - $128,519 / ANNUAL

• Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.

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