**Job Description** **Job Summary** The AVP, Clinical Validation (PI) role within Payment Integrity utilizes clinical background and relevant experience to lead the Clinical Operations team, consisting of clinical staff and certified coders, to grow overpayment identification, drive savings, and manage administrative costs. This position partners with Shared Services, Health Plans, and senior leadership to identify opportunities to drive positive operational and financial outcomes. **Work Location - Remote within the United States** **Job Duties** • Lead Molina’s payment integrity Clinical Operations team that has oversight for both Pre-pay and Post-pay DRG validation, Itemized Bill Review and Medical Record Review end-to-end process. • Leads a team of clinical staff and certified coders to validate coding accuracy including billed diagnosis, procedure codes and billed charges that are supported by available clinical information and the appropriateness of treatment setting and services delivered. • Responsible for content development / refinement, including oversight of vendor content, and partners with root cause analysis team to drive content optimization / minimize dispute overturn rates. • Provides strategic leadership for both pre-pay and post-pay clinical review programs to grow overpayment identification, drive savings results, and manage administrative costs. • Creates and drives a culture of collaboration enabling leaders and associates alike to thrive in a fast-paced environment. • Utilizing clinical background and relevant experience, position has oversight for creation, publication, and maintenance of DRG Validation clinical policies to support Clinical review program and cases with high potential of upcoding. • Consistently analyzes dispute overturn data to identify trends at the DRG, Provider, LOB, and HP level to maximize cost savings potential while reducing provider abrasion. • Partners with Shared Services departments to set up operational workflows to efficiently review high volumes of claims and maintain compliance TAT requirements. • Partners with HP CMOs, Utilization Management, and Shared Services teams to identify Pre-Pay and Post-Pay cost saving opportunities. • Ensures the achievement of financial objectives and operational excellence. • Using clinical experience, provides coaching to staff through sample auditing to improve the quality of DRG reviews. Analyzing SLA parameters with team performance and planning continuous improvement in performance, process optimization, adherence to reporting schedules and maintaining all necessary process documentation as per the process protocol. • Attends Joint Operation Committee (JOC) meetings with HPs and Providers to support Clinical Review initiatives. • Monthly business review meeting with executive leadership team, business stakeholders and ensures the resolution of all issues to the satisfaction of Molina’s local Health Plan business partners. Other duties which are of secondary importance to the position's purpose: • Claims Adjudication accuracy including configuration in QNXT (i.e. Claims Production, Audit, Production Vendor Oversight) for all lines of business. Claims Shared Services for all lines of business (i.e. activities supporting the production of claims including but not limited to the Corporate Recovery Team, Corporate Claims Compliance Team, Support Services, Enrollment and Billing, Corporate Encounter Team as well as providing overall organizational leadership of claims editing and recovery vendors aimed at managing overall healthcare costs). • Corporate Configuration of the QNXT system for all lines of business, which may also include the Care Management application for UM functions within QNXT: + Meeting state regulatory requirements + Enabling the system to produce expected health care costs + Improving the quality of the provider payments + Reducing G&A costs as part of the enterprise-wide efforts to meet or exceed budget targets and to consistently to reduce G&A + Continuing to drive positive operational and financial outcomes within the other Provider Payment Initiatives **Job Qualifications** **REQUIRED EDUCATION:** Bachelor’s Degree in Healthcare Administration or Health Information Management or appropriate relevant healthcare experience **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:** • Minimum of 7 years Healthcare experience in related job or Operational experience • Specific experience and demonstrated success in relevant Clinical Review Programs • 5+ years Managed Care payor experience, preferably Medicare / Medicaid experience • Rich understanding of ICD-9/10CM, MS-, AP- and APR-DRG reimbursement required • 5+ years of experience in a leadership role; demonstrated success in managing a team / leading a department • Experience with hospital EMRs, EPIC Payor Platform, and medical record repositories • Strong strategic thinking skills with ability to translate strategy into operational goals, excellent collaboration, financial, analytical, and change management skills strongly preferred • Excellent verbal and written communication skills • Excellent organizational and people management skills • Ability to influence and drive change among peers and others within the Molina organization • Skill to envision, craft proposals, obtain consensus around approving and implementing future payment ideation initiatives and systems needed to support strategic direction set by organization. • Ability to maintain standards to support required quality and quantity of work • Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) • Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers • Travels to worksite and other locations as necessary (limited basis) **PREFERRED EDUCATION:** Master’s Degree **PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:** • Coding Certification / Inpatient Coding Credential (CCS, CIC, CDIP or CCDS) • Registered Health Information Administrator (RHIA) • Registered Health Information Technician (RHIT) 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. Pay Range: $140,795 - $274,550 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.