Analyst, Configuration Oversight (QNXT & Medicare) - Remote

Analyst, Configuration Oversight

Job Summary

Responsible for administering audits related to accurate and timely implementation and maintenance of critical information on claims databases. Validate data housed on databases and ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements. Maintain audit records, and provide counsel regarding coverage amount and benefit interpretation within the audit process. Monitors and controls backlog and workflow of audits. Ensures that audits are completed in a timely fashion and in accordance with audit standards.

Knowledge/Skills/Abilities

• Analyze and interpret data to determine appropriate configuration changes.
  


• Accurately interprets specific state and/or federal benefits, contracts as well as additional business requirements and converting these terms to configuration parameters.
  


• Validates coding, updating and maintaining benefit plans, provider contracts, fee schedules and various system tables through the user interface.
  


• 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 and is able to prioritize work to meet deadlines and needs of department.



• 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 processing system (QNXT).



• Conducts focal audits on samples of processed transactions impacted by these updates/changes. Determines that all outcomes are aligned to the original documentation and allow appropriate processing.



• Clearly documents the focal audit results and makes recommendations as necessary.



• 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.



• 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:

• 2-5

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

PREFERRED EDUCATION:

Bachelor’s Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE:

5-7 years

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

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