Job Description

JOB DESCRIPTION Job Summary

JOB SUMMARY

Responsible for accurately interpreting regulatory requirements related to coverage, reimbursement, and claims processing, then translating them into documented system configuration requirements. Partners with stakeholders, subject matter experts, and governance committees to support compliant, timely claim payment solutions.

DUTIES AND RESPONSIBILITIES

• Interprets state, federal, contractual, benefit, and business requirements and translates them into clear configuration parameters.
• Develops and maintains requirements documentation for coverage, reimbursement, claims processing, and related configuration requirements.
• Monitors regulatory and industry updates to identify prospective and retrospective impacts to products, payments, compliance, and financial performance.
• Coordinates benefit and requirement interpretation reviews, governance activities, approvals, and implementation timelines with health plans and corporate partners.
• Communicates requirement decisions and changes to impacted stakeholders, ensuring end-to-end documentation, alignment, approval, and solution traceability.
• Supports defect resolution, complaints, and claim or requirement interpretation issues for assigned components.
• Develops standards and best practices that improve the consistency, quality, and efficiency of requirement interpretation and configuration across states and products.
• Provides concise reporting and analysis on work status, regulatory changes, claim trends, appeals and grievances, compliance issues, and potential financial impacts.
• Partners with Regional Product Managers, Configuration, Medical Management, Clinical Operations, and other teams to align filed benefits, coding, prior authorization, and system requirements.
• Researches industry practices and recommends appropriate improvements for adoption.
• Leads complex, cross-functional projects with limited direction while balancing multiple states, products, and requirement areas.
• Builds effective relationships across Health Plans and Corporate functions and communicates clearly with employees at all organizational levels.
• Synthesizes large, complex requirements into concise, actionable guidance.
• Organizes and maintains regulatory information, including real-time policy and legislative changes.
• Works independently in a remote, multi-time-zone environment; takes initiative to identify, communicate, and resolve issues.
• Manages competing priorities and aggressive timelines while maintaining quality and accuracy.
• Supports implementation and conversion activities for new and existing health plans, including application upgrades, releases, and test planning and execution.
• Collaborates with health plans and corporate partners to define business objectives, document end-to-end requirements, and negotiate achievable completion dates.
• Serves as a core system management subject matter expert and helps leadership establish standards, guidelines, and best practices.
• Creates reporting tools and status communications for configuration updates, initiatives, and department-wide projects.
• Trains and supports new and existing team members on configuration functionality, enhancements, and updates.
• Manages fluctuating workloads and prioritizes assignments to meet department and user-community deadlines.

REQUIRED QUALIFICATIONS

• Five or more years of core system management, database maintenance, or analyst experience in managed care operations supporting Medicaid, Medicare, and/or Marketplace programs; an equivalent combination of education and experience may be considered.
• Advanced experience with claims processing systems, including validating documentation for system updates and changes.
• Strong analytical, critical-thinking, problem-solving, and attention-to-detail skills.
• Ability to adapt to changing business needs while delivering accurate, high-quality work on time.
• Effective written and verbal communication skills.
• Proficiency with Microsoft Office, including intermediate to advanced Excel skills such as VLOOKUPs and PivotTables.
• Familiarity with claims processing and administration systems such as QNXT and Networx Pricer.

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