What are the responsibilities and job description for the Director, Configuration (EDI - Claims) position at Molina Healthcare Group?
Job Description
Job DescriptionJob Summary
Responsible for all Configuration Information Management operational activities for the assigned team, including accurate and timely implementation and maintenance of critical information on claims databases. Validate data to be housed on databases and ensure adherence to business and system requirements of Health Plans as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements.
Knowledge/Skills/Abilities
Leadership, Management, Strategic Capability, Talent Management, Compliance
• Strategically plans, leads, and manages the overall Configuration staff and workflow processes.
- Planning
- Continuously identify and execute opportunities for operational efficiency and develop a best practice approach to assigned operational areas to accomplish the organization and department goals.
- Ensure appropriate resources are available to achieve department goals. Communicate any needed resources, rationale, and deficiencies to Leadership.
- Identify and implement strategic process improvements with valuable ROI
- Leadership
- Promote the success of the company.
- Focus on the overall goals for the department and Molina.
- Lead department to make it a high performing unit. Implement policy and procedure as appropriate.
- Exercise reasonable care, skill, and diligence
- Ensure quality work is being delivered.
- Management
- Responsible for the department's overall performance. Meet and exceed all performance metrics and department goals.
- Understand conflicts with teams and provide solutions.
- Ensure all team members comply with company and legal requirements.
- Tasks are completed with accuracy and efficiency. Sets the right priorities and systematically identifies the root cause of challenges.
- Ensure staff have all the resources they need to perform at an elevated level.
- Conduct performance reviews, training, and corrective action as appropriate.
Technical knowledge/skills/abilities:
• Establishes and maintains benefits, provider contracts, fee schedules, claims edits, and other system settings in the claim payment system.
• Directs the development and implementation of contract and benefit configuration as well as fee schedules.
• Directs the implementation and maintenance of member benefits in the claims payment system and other applicable systems.
Business Acumen/Collaboration/Communication
• Supports critical business strategies by providing systematic solutions and or recommendations on business processes.
Job Qualifications
- Plan for long-term success of the department and individual Health Plans with a focus on goals and improvement to daily operations.
- Build and maintain strong trusted relationships with key stakeholders such as the Health Plan and other departments utilizing excellent communication and collaboration skills. Present data and opportunities to Health Plan for collaboration and accountability.
- Coordinate activities of assigned work function and/or department with related activities of other work functions and/or departments to ensure efficiency and proper prioritization.
- Utilizes superior judgement in evaluating various approaches to limit risk and communicating risk to appropriate stakeholders.
- Ensures appropriate follow up and communication occurs on items assigned directly, and to team members.
- Excellent written and verbal communication skills; ability to communicate complex information in an easy-to-understand manner
Skills/Knowledge/Abilities
- Understanding of complex payment methodologies
- Understanding of complex configuration solutions
- Advanced knowledge of health care benefits.
- Advanced knowledge of Excel
- SQL knowledge preferred
- Advanced knowledge of healthcare claims and claim processing from receipt through encounter submission.
- Ability to adopt and utilize work tracking software
- Coding certification preferred
Job Qualifications
Required Education:
Graduate degree or equivalent combination of education and experience.
Required Experience:
7-9 Years
Preferred Education:
Graduate degree or equivalent combination of education and experience.
Preferred Experience:
10 Years
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.
Job Info
Job Identification: 2029437
Job Category: Operations
Posting Date: 2025-01-03T15:22:06 00:00
Job Schedule: Full time
