Lead Analyst, Configuration Oversight (COB/ Audit Quality & Accuracy/ Claims Configuration)

Molina Healthcare; Northern (KY); Hybrid; USD 60,000 - 130,000; Full time

Job summary

Molina Healthcare seeks an experienced audit professional to oversee accuracy of claims databases and configurations across contracts, benefits, and authorizations. You will train staff, interpret complex requirements, and deliver clear audit results.

Responsibilities include leading projects, mentoring junior auditors, and ensuring timely, standards-compliant audits across multiple states using QNXT, AutoQ, and MRDT tools.

Qualifications

• Bachelor’s Degree or equivalent combination of education and experience.
• 5-6 Years of experience required.
• Graduate Degree preferred; 7+ Years preferred.

Responsibilities

• Audit critical information on claims databases accurately and timely.
• Synchronize data among systems and apply business rules as they pertain to each database.
• Validate configuration accuracy per contracting, benefits, prior authorizations, fees, and other requirements.
• Assign workload to auditors and monitor workflow.
• Train and coach new employees and mentor junior staff.
• Provide clear results and comments to leaders about focal and random audits across states.
• Ensure audits are conducted timely and in line with standards.

Skills

Staff training

Requirements analysis

Management reporting

Ad-hoc reporting

Mentoring

Project leadership

Communication of findings

Education

Bachelor’s Degree or equivalent

Graduate degree preferred

Tools

QNXT

AutoQ

MCG

MRDT

Job description

KNOWLEDGE, SKILLS&ABILITIES(Generally, theoccupational knowledgeand specifictechnical and professional skills andabilities requiredtoperformtheessential dutiesofthis job):

• Trains audit staff on configuration functionality, enhancements and updates.
• Accurately interprets end to end business requirements and able to confirm outcomes meet the specific state/federal requirements.
• Creates management reporting tools to enhance audit communication on configurations accuracy results and/or audit findings
• Writes complex ad-hoc report
• Interprets and validates accuracy of complex MRDT and other configuration update scripts
• Assists manager in establishing standards, guidelines, and best practices for the audit team
• Interprets and validates accuracy of complex reports and automated configuration processes/solutions
• Assist manager in establishing peer review standards and methodolog
• Leads peer reviews
• Research and review new audit tools and techniques and provide recommendations to management
• Validates accuracy of new complex configuration processes/solutions
• Verifies accuracy of MRDT, fee schedule, premium, AutoQ, and other file load packages
• Interprets complex business problems and technical issues
• Effectively communicates audit findings and/or outcomes through review meetings, written communications, and, workflow diagrams.
• Helps drive solution to successful implementation by directing technical and business resources during all phases of the software development life cycle
• Gains a deep understanding of Molina claims life cycle and all processes that affect claims payment
• Develops and maintain standards and best practices for the team
• Mentors junior auditors
• Participates in or leads project meetings
• Understands QNXT, AutoQ, and MCG functionality and schema
• Writes Requirements for BRDs/FRDs and Reports without needing mentoring
• Suggests schema/solution. Works with technical resource to determine best solution.
• Manages complex projects from requirements to deployment, including work assignment, prioritization, issue triage etc.
• Researches complex issues\
• Acts as a team lead, assigning and prioritizing work for other team members as needed

JOBFUNCTION:

• Responsible for accurate and timely auditing of critical information on claims databases.
• Maintains critical auditing and outcome information. Synchronizes data among operational and claims systems and application of business rules as they apply to each database.
• Validate accuracy of configuration and ensure adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements.
• Responsible for work load assignment to auditors.
• Train and coach new employees .
• Provide clear and concise results and comments to leaders about focal and and random audits across all states.
• Monitors and controls workflow.
• Ensures that audits are conducted in a timely fashion and in accordance with unit standards.

REQUIREDEDUCATION:

Bachelor’s Degree or equivalent combination of education and experience

REQUIREDEXPERIENCE:

5-6 Years

PREFERREDEDUCATION:

Graduate Degree or equivalent experience

PREFERREDEXPERIENCE:

7+ Years

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $59,810.6 - $129,589.63 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.