Claims Audit & Configuration Specialist

Molina Healthcare, Inc.; United States; Presencial; USD 30.000 - 56.000; Jornada completa

Descripción de la vacante

Molina Healthcare is seeking an Audit Specialist to support configuration oversight for audits across vendor, focal, and auditor activities. You will review documentation for claims accuracy, perform focal and vendor audits, document outcomes, and communicate findings in alignment with audit standards.

Responsibilities include tracking errors, evaluating adjudication accuracy against state policies, and delivering timely audit reports with leadership recommendations.

Formación

• At least 2 years of auditing experience in a health care operations setting.
• Experience using a claims processing system.
• Experience verifying documentation related to updates/changes within claims processing system.
• Flexibility to meet changing business requirements with focus on quality and timeliness.
• Strong attention to detail and effective communication skills.
• Proficiency with Microsoft Office, including Excel.

Responsabilidades

• Review documentation of member enrollment, provider contracts, demographics, and claim processing guidelines for accuracy in the core claims system.
• Conduct focal audits on processed transactions and verify alignment with original documentation.
• Audit vendor audits and verify accuracy of published outcomes.
• Document and assess focal audit results clearly.
• Track unresolved errors and coordinate with operations to resolve within 30 days.
• Evaluate claims adjudication for incorrect coding, fraud, waste, or processing errors using policy guidance.
• Prepare and present audit findings with recommendations to leadership.

Conocimientos

Auditing in healthcare

Attention to detail

Verbal and written communication

MS Office proficiency

Herramientas

Claims processing system

Microsoft Excel

Descripción del empleo

Molina Healthcare is seeking an Audit Specialist to support configuration oversight for audits across vendor, focal, and auditor activities. You will review documentation for claims accuracy, perform focal and vendor audits, document outcomes, and communicate findings in alignment with audit standards.

Responsibilities include tracking errors, evaluating adjudication accuracy against state policies, and delivering timely audit reports with leadership recommendations.