Specialist, Configuration Oversight

Provides support for configuration oversight activities specific to various audits including vendor, focal, and audit the auditor. Auditing responsibilities include: reviewing documentation to ensure claims information accuracy/adherence to business and system requirements as it pertains to contracting, network management, credentialing, prior authorizations, fee schedules, and other business requirements critical to claim accuracy, providing counsel related to coverage amounts and benefit interpretation, and provision of clear and concise audit results and commentary in alignment with audit standards. Contributes to compliance, regulatory oversight and monitoring - ensuring improvement in functional support areas., * Reviews documentation related to updates/changes to member enrollment, provider contracts, provider demographic information, and/or claim processing guidelines; evaluates the accuracy of these updates/changes as applied to the appropriate modules within the core processing claims system.

• Conducts focal audits on samples of processed transactions impacted by updates/changes; determines that outcomes are aligned to original documentation for appropriate processing.
• Conducts audits of vendor audits and verifies that accuracy of published outcomes are aligned to documentation; ensures that various sources of truth are assessed appropriately.
• Clearly documents and assesses focal audit results.
• 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.
• Evaluates 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 leadership for improvements based on audit results.
• Manages fluctuating volumes of work, and prioritizes work to meet deadlines and needs of the configuration department and user community.

• At least 2 years of experience as an auditor within a health care operations setting, or equivalent combination of relevant education and experience.
• Experience using a claims processing system.
• Experience verifying documentation related to updates/changes within claims processing system.
• 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 (including Excel), 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