Job Description

JOB DESCRIPTION Job Summary

Leads and supervises team responsible for payment integrity activities including recovery operations. Responsible for performance, quality levels and establishing procedures and techniques that achieve optimal payment integrity operational standards and production targets.

Essential Job Duties

• Supports implementation and execution of initiatives that include one or all of the following payment integrity activities: overpayment recovery, pre and post-pay coordination of benefits (COB), subrogation, premium enhancement managed service provider (MSP), datamining, pre-pay editing for correct coding and medical payment policies, and supplemental oversight and vendor inventory management processing activities.

• Hires, trains, develops, mentors, and manages team responsible for executing projects and activities involving inventory management and prioritization, information reporting, data management, quality control procedures and workflows, and timely turnaround.

• Leads recovery processing, offset reconciliation, refund posting and reconciliation, provider dispute resolution, claim referrals and health plan special projects.

• Ensures team meets or exceeds production targets.

• Executes payment integrity programs that prioritize, identify and resolve payment/recovery issues.

• Establishes procedures and techniques to achieve payment integrity operational standards.

• Executes and monitors recovery inventory to ensure maintenance of performance and quality levels in payment integrity business products and processes.

• Demonstrates expertise in claims processing, claims payment issue resolution, payment/adjustment error troubleshooting, and quality controls recovery adjustments.

• Professionally communicates and responds to health plan/provider inquiries and understands when to escalate issues for resolution as appropriate.

• Manages inventory production queues, and assigns and prioritizes work.

• Analyzes complex data driven reports and develops actionable insights for resolution and leadership reporting.

• Collaborates with payment integrity leadership to resolve recovery issues in collaboration with health plan operations.

• Executes tasks and projects to ensure Centers for Medicare and Medicaid Services (CMS) and state regulatory requirements are met for pre-pay edits, overpayment recovery, COB and subrogation - ensuring improved encounter submissions, general and administrative (G&A) reduction, and positive operational and financial outcomes for the payment integrity function.

Required Qualifications

• At least 5 years of experience supporting health care operations, including 3 years payment integrity/claims experience, or equivalent combination of relevant education and experience.

• Ability to establish and maintain positive and effective work relationships with coworkers, members, providers and customers.

• Strong organizational and time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.

• Effective verbal and written communication skills.

• Microsoft Office suite and applicable software program(s) proficiency.

Preferred Qualifications

• Management/leadership experience.
• Managed care payor experience, preferably with Medicare/Medicaid.
• Understanding of ICD-9/10CM, MS-, AP- and APR-DRG reimbursement.
• Electronic medical record (EMR) and medical record repository experience.

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