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

Molina Healthcare; United States; On-site; USD 90,000 - 130,000; Full time

Job summary

Molina Healthcare is seeking an experienced audit professional to lead the review of configuration accuracy across claims databases and related systems. You will train staff, validate complex MRDT and fee schedule updates, and translate business rules into clear audit findings.

Responsibilities include planning audits, assigning work, mentoring junior auditors, and presenting results to leadership while ensuring compliance with state and federal requirements.

Qualifications

• Bachelor’s Degree or equivalent combination of education and experience.
• 5-6 years of auditing experience, preferably in healthcare or claims.
• Graduate degree preferred for more seniority.
• Strong knowledge of internal controls and regulatory requirements.

Responsibilities

• Audit critical information on claims databases with accuracy and timeliness.
• Assign workloads and monitor auditor performance.
• Train and coach new employees to standard practices.
• Present results clearly to leaders and stakeholders.
• Lead peer reviews and drive project meetings.

Skills

Audit staff training

Requirements interpretation

Management reporting

Ad-hoc reporting

MRDT validation

Best practices

Peer reviews

Audit tools research

Complex report validation

Team leadership

QNXT knowledge

Requirements documentation

Mentoring

Project coordination

Issue research

Team lead

Education

Bachelor’s Degree

Tools

QNXT

AutoQ

MCG

Job description

KNOWLEDGE, SKILLS & ABILITIES

(Generally, theoccupational knowledgeandspecifictechnical 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