**JOB DESCRIPTION**
**Job Summary**
Provides senior level support for accurate and timely intake and interpretation of regulatory and/or functional requirements related to but not limited to coverage, reimbursement, and processing functions to support systems solutions development and maintenance. This role includes coordination with stakeholders and subject matter experts on partnering teams and supporting governance committees where applicable.
**JOB DUTIES**
+ Develops and maintains requirement documents related to coverage, reimbursement and other applicable system changes in areas to ensure alignment to regulatory baseline requirements and any health plan/product team developed requirements.
+ Monitors regulatory sources to ensure all updates are aligned as well as work with operational leaders within the business to provide recommendations for process improvements and opportunities for cost savings.
+ Leads coordinated development and ongoing management /interpretation review process, committee structure and timing with key partner organizations. Interpret customer business needs and translate them into application and operational requirements.
+ Communicates requirement interpretations and changes to health plans/product team and various impacted corporate core functional areas for requirement interpretation alignment and approvals as well as solution traceability through regular meetings and other operational process best practices.
+ Where applicable, codifies the requirements for system configuration alignment and interpretation.
+ Provides support for requirement interpretation inconsistencies and complaints.
+ Assists with the development of requirement solution standards and best practices while suggesting improvement processes to consistently apply requirements across states and products where possible.
+ Self-organized reporting to ensure health plans/product team and other leadership are aware of work efforts and impact for any prospective or retrospective requirement changes that can impact financials.
+ Coordinates with relevant teams for analysis, impact and implementation of changes that impact the product.
+ Engages with operations leadership and Plan Support functions to review compliance-based issues for benefit planning purposes.
**Recoveries & Disputes**
+ Review and validate provider complaints and payment disputes, ensuring accurate and timely resolution in line with policy and contractual guidelines.
+ Partner with provider relations, Health plans and appeals teams to address recurring dispute trends and recommend systemic solutions.
+ Evaluate root cause for the disputes and recommend improvements to reduce claim errors and prevent improper payments.
+ Provide actionable insights and recommendations to leadership to drive continuous improvement.
**Skills & Competencies**
+ Proven experience handling provider disputes, appeals, and overpayment recoveries in a managed care or payer environment.
+ In-depth knowledge of medical and hospital claims processing, including CPT/HCPCS, ICD, and modifier usage.
+ Strong understanding of claim system configurations, payment policies, and audit processes.
+ Exceptional analytical, problem-solving, and documentation skills.
+ Ability to translate complex business problems into clear system requirements and process improvements.
+ Proficiency in Excel
+ Knowledge in QNXT preferred
+ Strong communication and stakeholder management skills with ability to influence across teams.
**KNOWLEDGE/SKILLS/ABILITIES**
+ Maintains relationships with Health Plans/Product Team and Corporate Operations to ensure all end-to-end business requirements have been documented and interpretation are agreed on and clear for solutioning.
+ Ability to meet aggressive timelines and balance multiple lines of business, states, and requirement areas.
+ Strong interpersonal and (oral and written) communication skills and ability to communicate with those in all positions of the company.
+ Ability to concisely synthesize large and complex requirements.
+ Ability to organize and maintain regulatory data including real-time policy changes.
+ Self-motivated and ability to take initiative, identify, communicate, and resolve potential problems.
+ Ability to work independently in a remote environment.
+ Ability to work with those in other time zones than your own.
**JOB QUALIFICATIONS**
**Required Qualifications**
+ At least 4 years of experience in previous roles in a managed care organization, health insurance or directly adjacent field, or equivalent combination of relevant education and experience.
+ Policy/government legislative review knowledge
+ Strong analytical and problem-solving skills
+ Familiarity with administration systems
+ Robust knowledge of Office Product Suite including Word, Excel, Outlook and Teams
+ Previous success in a dynamic and autonomous work environment
**Preferred Qualifications**
+ Project implementation experience
+ Knowledge and experience with federal regulatory policy resources including Centers for Medicare & Medicaid Services (CMS) and the Affordable Care Act (ACA).
+ Medical Coding certification.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $77,969 - $128,519 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.