AVP, Payment Integrity (Data Analytics)

Job Description 
Job Summary 
Responsible for planning, developing and directing the implementation of techniques to ensure the maintenance of performance and quality levels in the Business' products and processes. Reviews operation process designs and establishes procedures and techniques for operational standards. Confers with customers to define and resolve 
 

 Knowledge/Skills/Abilities 
Lead Molina’s Payment Integrity Data Analytics operations team that has oversight for Content Ideation, Research and Edit Development teams in support of our cross-functional Payment Integrity organization

• Responsible for concept development / refinement & root cause analysis team to drive content optimization / minimize dispute overturn rates. Utilize algorithms and models to mine big data, improve models, and ensure data uniformity and accuracy.
• Lead strategic analysis and planning across business units to meet data analysis needs.
• Develop scalable, efficient, and automated processes for large-scale data analyses and model development.
• Strong strategic thinking with ability to translate strategy into operational goals, excellent collaboration, financial, analytical, and change management skills strongly preferred.
• Demonstrated critical thinking and ability to bring order to unstructured problems.
• Creates and drives a culture of collaboration enabling leaders and associates alike to thrive in a fast-paced environment.
• Works independently, demonstrates initiative and innovative thinking, clear and concise communication skills.
• Identifies technical improvements needs to expand concept ideation: connection with new databases, report monitoring, BOTs/Automation, etc.
• Monthly business review meeting with executive leadership team, business stakeholders and ensures the resolution of all issues to the satisfaction of Molina’s local Health Plan business partners

• Consistently analyzes dispute overturn data to identify trends at the Provider, LOB, and HP level to maximize cost savings potential while reducing provider abrasion.
• Ensures the achievement of financial objectives and operational excellence
• Proven ability to coach, develop and engage strong teams. Hires, trains, coaches, counsels and evaluates performance of direct reports.
• Team management Performance review of team members at regular intervals 

Other duties which are of secondary importance to the position's purpose.

• Claims Adjudication accuracy including configuration in QNXT (i.e. Claims Production, Audit, Production Vendor Oversight) for all lines of business. Claims Shared Services for all lines of business (i.e. activities supporting the production of claims including but not limited to the Corporate Recovery Team, Corporate Claims Compliance Team, Support Services, Enrollment and Billing, Corporate Encounter Team as well as providing overall organizational leadership of claims editing and recovery vendors aimed at managing overall healthcare costs).
• Corporate Configuration of the QNXT system for all lines of business, which may also include the Care Management application for UM functions within QNXT:
  • Meeting state regulatory requirements;
  • Enabling the system to produce expected health care costs;
  • Improving the quality of the provider payments;
  • Reducing G&A costs as part of the enterprise-wide efforts to meet or exceed budget targets and to consistently to reduce G&A
  • Continuing to drive positive operational and financial outcomes within the other Provider Payment Initiatives 

Job Qualifications

Required Education

• Bachelor’s degree in Healthcare Administration or Health Information Management (HIM, RHIA or RHIT), or Information Systems / Technology or related field.
• Master's Degree preferred

Required Experience
 

• Minimum of 7 years Healthcare experience in related job or Operational experience
• Specific experience and demonstrated success in Payment Integrity; preferably leading content development.
• 5+ years Managed Care payor experience, preferably Medicare / Medicaid experience. 
• Rich understanding of claim reimbursement across all Medical spend types and both State & Federal reimbursement methodologies / guidelines
• Technical experience / understanding of data systems and edit configuration, such as SQL, Python, Poer BI, Databricks, etc. 
• 5+ years of experience in a leadership role; demonstrated success in managing / leading teams 
• Excellent verbal and written communication skills
• Excellent organizational and people management skills
• Ability to influence and drive change among peers and others within the Molina organization
• Skill to envision, craft proposals, obtain consensus around approving and implementing future payment ideation initiatives and systems needed to support strategic direction set by organization.
• Ability to maintain standards to support required quality and quantity of work
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers.
• Travels to worksite and other locations as necessary (limited basis).

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.