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

• 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.

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.
• Knowledge of relevant CMS rules and/or State regulations with different line of business as: Medicare, Medicaid, Marketplace, Dual coverages/COB.
• 2+ years of comprehensive claim audits as 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 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

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

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