Job Description

Provides senior-level support for the accurate and timely intake, interpretation, and translation of regulatory, business, and functional requirements. This role requires strong depth in claims operations and policy interpretation, along with a solid, practical understanding of Availity as a key provider-facing platform. The position partners closely with claims operations, health plans, product, and digital channel teams to ensure claims-related requirements are clearly defined, governed, and implemented in support of compliant and efficient systems solutions.

JOB DUTIES

• Communicates requirement interpretations and changes to health plans/product team and various impacted corporate core functional areas for requirement interpretation alignment and approvals as well as solution traceability through regular meetings and other operational process best practices.
• Monitors regulatory sources to ensure all updates are aligned. Uses comprehensive background to navigate analytical problems, including: clearly defining and documenting their unique specifications. Leads coordinated development and ongoing management / interpretation review process, committee structure and timing with key partner organizations.
• Recognizes, identifies and documents changes to existing business processes and identifies new opportunities for process developments and improvements.
• Provides status and updates to health plan/product team partners, senior management and stakeholders.
• Partners with claims operations, product, IT, and digital channel teams to ensure claims requirements are accurately reflected across systems, including provider-facing tools such as Availity.
• Applies working knowledge of Availity functionality to support claims-related workflows, including claims submission, claims status, remittance, and payment inquiries, ensuring requirements align with platform capabilities.
• Coordinates analysis, impact assessment, and implementation activities for claims-related changes.
• Engages with claims leadership and Plan Support functions to review compliance-driven issues and support benefit and reimbursement planning.

KNOWLEDGE/SKILLS/ABILITIES

• Deep expertise in managed care claims operations, including claims processing, reimbursement methodologies, and a working knowledge of Availity as a provider-facing platform for claims submission, status, and payment inquiries.
• Maintains relationships with Health Plans/Product Team and Corporate Operations to ensure all end-to-end business requirements have been documented and interpretation are agreed on and clear for solutioning.
• Ability to meet aggressive timelines and balance multiple lines of business, states, and requirement areas.
• Proven ability to lead complex, cross-organizational projects independently, navigating ambiguity with minimal direction.
• Strong interpersonal and (oral and written) communication skills and ability to communicate with those in all positions of the company.
• Ability to concisely synthesize large and complex requirements.
• Ability to organize and maintain regulatory data including real-time policy changes.
• Self-motivated and ability to take initiative, identify, communicate, and resolve potential problems.
• Ability to work independently in a remote environment.
• Ability to work with those in other time zones than your own.

JOB QUALIFICATIONS

Required Qualifications

• At least 4 years of experience in previous roles in a managed care organization, health insurance or directly adjacent field, or equivalent combination of relevant education and experience.
• Policy/government legislative review knowledge
• Strong analytical and problem-solving skills
• Familiarity with administration systems
• Robust knowledge of Office Product Suite including Word, Excel, Outlook and Teams
• Previous success in a dynamic and autonomous work environment

Preferred Qualifications

• Project implementation experience
• Knowledge and experience with federal regulatory policy resources including Centers for Medicare & Medicaid Services (CMS) and the Affordable Care Act (ACA).
• Medical Coding certification.

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.