Analyst, Configuration Oversight (Claims Auditor)

Job Description

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.

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

Job Duties for this position :

• 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

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 :

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.

2+ years of comprehensive claim audits as preference

Knowledge of relevant CMS rules and / or State regulations with different line of business as : Medicare, Medicaid, Marketplace, Dual coverages / COB.

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.

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