Analyst, Configuration Oversight (Claims Auditor)

Overview

Responsible for comprehensive contract review and target claim audits review. This includes but not limited to; deep dive contract review and targeted claim 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 stakeholders as it pertains to provider contracting, network management, credentialing, 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 that the configured services are correct. Maintain the audit workbooks and provide summation regarding the assigned tasks. Manage findings follow-up and tracking with stakeholders / requestors.

Responsibilities

• Analyze and interpret data to determine appropriate configuration.
• Comprehensive understanding of contracts reviews to detect any gaps in the correct payment of claims.
• Make recommendations for potential revision and updates.
• Interprets accurately specific state and / or federal benefits, contracts as well as additional business requirements and converting these terms to configuration parameters.
• Ability to interpret contract term agreements pertaining to Line of Business (LOB) and States for all different claim types and services billed under Institutional and non-institutional claims.
• Validates coding, updating and maintaining benefit plans, provider contracts, fee schedules and various system tables through the user interface to ensure current contract and / or amendment rates align in our system.
• 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, various audit types and must be able to prioritize work to meet deadlines and Business Needs.
• 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).
• Clearly documents the audit results and makes recommendations as necessary.
• 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.

Qualifications

REQUIRED EDUCATION :

Associate's degree or equivalent combination of education and experience

REQUIRED EXPERIENCE / KNOWLEDGE, SKILLS & ABILITIES :

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

3+ years of experience in claims as Adjuster or claims examiner in the healthcare field

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.

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

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