JOB DESCRIPTION

Job Summary

Performs research and analysis of complex healthcare claims data, pharmacy data, and contract data regarding network utilization and cost containment information. Evaluates, writes, and presents healthcare utilization and cost containment reports and makes recommendations based on relevant findings. This position is responsible for proactively identifying claim issues, resolving disputes, and coordinating solutions while overseeing and managing the activities of assigned providers from initiation to completion of the program. This role contributes to the strategic direction and organization of health plan initiatives, facilitating the successful implementation of provider engagement programs.

Duties and Responsibilities (List all essential duties and responsibilities in order of importance)

Analyze claims from compliance against contracts, billing, and processing guidelines Analyze data sets and trends for anomalies, outliers, trend changes, and opportunities to recommend policy changes Assist with research, development and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations. Responsible for timely completion of projects, including timeline development and maintenance, and coordination of activities and data collection with requesting internal departments or external requestors. Initiate in-depth analysis of the suspect/problem areas and suggest a corrective action plan Demonstrate Healthcare experience in Quantifying, Measuring and Analyzing Financial and Utilization Metrics of Healthcare. Collaborates with internal departments to determine root cause and analytical approach to payment discrepancies. Apply investigative skills and analytical methods to look behind the numbers, assess business impacts, and make recommendations through use of healthcare analytics, predictive modleing, etc. Interact with various departments including; IT, Contracting, Corporate Services, Claims, Utilization Management and Payment Integrity to understand claim related policies and payment processes, member benefits, contracts and State requirements Responsible for documenting policies and procedures related to concept approvals Participate in and support the development of strategies to meet the business needs Implement and use software and systems to support the department’s goals. Other duties as assigned

 

State Plan / Department Specific Duties and Responsibilities (List all essential duties other than those listed above in order of importance)

Ability to practice Service Excellence (Molina Kentucky)

JOB QUALIFICATIONS

Required Education

Bachelor's Degree in Finance, Economics, Computer Science

Required Experience

5-7 years increasingly complex database and data management responsibilities 5-7 years of increasingly complex experience in quantifying, measuring, and analyzing financial/performance management metrics          Demonstrate Healthcare experience in Quantifying, Measuring and Analyzing Financial and Utilization Metrics of Healthcare Basic knowledge of SQL Preferred Education Bachelor's Degree in Finance, Economics, Math, or Computer Science

Preferred Experience

Preferred experience in Medical Economics and Strong Knowledge of Performance Indicators:

Proactively identify and investigate complex suspect areas regarding medical cost issues Initiate in-depth analysis of the suspect/problem areas and suggest a corrective action plan Apply investigative skill and analytical methods to look behind the numbers, assess business impacts, and make recommendations through use of healthcare analytics, predictive modeling, etc. Analysis and forecasting of trends in medical costs to provide analytic support for finance, pricing and actuarial functions Healthcare Analyst I or Financial/Accounting Analyst I experience desired Multiple data systems and models BI tools                

 

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.