Company Detail

Medical Director (Must be licensed in MI) - Molina Healthcare
Posted: Sep 19, 2024 02:34
Louisville, KY

Job Description

JOB DESCRIPTION

Job Summary

Responsible for serving as the primary liaison between administration and medical staff. Assures the ongoing development and implementation of policies and procedures that guide and support the provisions of medical staff services. Maintains a working knowledge of applicable national, state, and local laws and regulatory requirements affecting the medical and clinical staff.

Job Duties

  • Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.

  • Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity.

  • Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff.

  • Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.

  • Reviews quality referred issues, focused reviews and recommends corrective actions.

  • Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.

  • Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer.

  • Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process.

  • Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care.

  • Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.

  • Ensures that medical protocols and rules of conduct for plan medical personnel are followed.

  • Develops and implements plan medical policies.

  • Provides implementation support for Quality Improvement activities.

  • Stabilizes, improves and educates the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed.

  • Fosters Clinical Practice Guideline implementation and evidence-based medical practice.

  • Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management.

  • Actively participates in regulatory, professional and community activities.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

  • Doctorate Degree in Medicine

  • Board Certified or eligible in a primary care specialty

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:

  • 3+ years relevant experience, including:

  • 2 years previous experience as a Medical Director in a clinical practice.

  • Current clinical knowledge.

  • Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.

  • Knowledge of applicable state, federal and third party regulations

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

Current state Medical (MI) license without restrictions to practice and free of sanctions from Medicaid or Medicare.

PREFERRED EDUCATION:

Master's in Business Administration, Public Health, Healthcare Administration, etc.

PREFERRED EXPERIENCE:

  • Peer Review, medical policy/procedure development, provider contracting experience.

  • Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.

  • Experience in Utilization/Quality Program management

  • HMO/Managed care experience

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Board Certification (Primary Care preferred).

PHYSICAL DEMANDS:

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

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.

Pay Range: $161,914.25 - $315,732.79 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Case Manager, LTSS Iowa (Lee/Van Buren/Henry County) - Molina Healthcare
Posted: Sep 19, 2024 02:34
Donnellson, IA

Job Description

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

  • Completes face-to-face comprehensive assessments of members per regulated timelines.

  • Facilitates comprehensive waiver enrollment and disenrollment processes.

  • Develops and implements a case management plan, including a waiver service plan, in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

  • Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

  • Promotes integration of services for members including behavioral health care and long-term services and supports, home and community to enhance the continuity of care for Molina members.

  • Assesses for medical necessity and authorize all appropriate waiver services.

  • Evaluates covered benefits and advise appropriately regarding funding source.

  • Conducts face-to-face or home visits as required.

  • Facilitates interdisciplinary care team meetings for approval or denial of services and informal ICT collaboration.

  • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

  • Assesses for barriers to care, provides care coordination and assistance to member to address psycho/social, financial, and medical obstacles concerns.

  • Identifies critical incidents and develops prevention plans to assure member's health and welfare.

  • 50-75% local travel required.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

  • Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or master's degree in a social science, psychology, gerontology, public health or social work OR any combination of education and experience that would provide an equivalent background

REQUIRED EXPERIENCE:

  • At least 1 year of experience working with persons with disabilities/chronic conditions and Long Term Services & Supports.

  • 1-3 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED EXPERIENCE:

  • 3-5 years in case management, disease management, managed care or medical or behavioral health settings.

  • 1 year experience working with population who receive waiver services.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Active and unrestricted Certified Case Manager (CCM)

Active, unrestricted State Nursing license (LVN/LPN) OR Clinical Social Worker license in good standing

Valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation

STATE SPECIFIC REQUIREMENTS:

For the state of Wisconsin:

Bachelor's degree or more advanced degree in the human services area and a minimum of one (1) year experience working with at least one of the Family Care target populations; or

Bachelor's degree or more advanced degree in any area other than human services with a minimum of three (3) years' experience working with at least one of the Family Care target populations.

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.

#PJHS

#LI-AC1

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Case Manager, LTSS Iowa (Lee/Van Buren/Henry County) - Molina Healthcare
Posted: Sep 19, 2024 02:34
Mount Pleasant, IA

Job Description

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

  • Completes face-to-face comprehensive assessments of members per regulated timelines.

  • Facilitates comprehensive waiver enrollment and disenrollment processes.

  • Develops and implements a case management plan, including a waiver service plan, in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

  • Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

  • Promotes integration of services for members including behavioral health care and long-term services and supports, home and community to enhance the continuity of care for Molina members.

  • Assesses for medical necessity and authorize all appropriate waiver services.

  • Evaluates covered benefits and advise appropriately regarding funding source.

  • Conducts face-to-face or home visits as required.

  • Facilitates interdisciplinary care team meetings for approval or denial of services and informal ICT collaboration.

  • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

  • Assesses for barriers to care, provides care coordination and assistance to member to address psycho/social, financial, and medical obstacles concerns.

  • Identifies critical incidents and develops prevention plans to assure member's health and welfare.

  • 50-75% local travel required.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

  • Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or master's degree in a social science, psychology, gerontology, public health or social work OR any combination of education and experience that would provide an equivalent background

REQUIRED EXPERIENCE:

  • At least 1 year of experience working with persons with disabilities/chronic conditions and Long Term Services & Supports.

  • 1-3 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED EXPERIENCE:

  • 3-5 years in case management, disease management, managed care or medical or behavioral health settings.

  • 1 year experience working with population who receive waiver services.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Active and unrestricted Certified Case Manager (CCM)

Active, unrestricted State Nursing license (LVN/LPN) OR Clinical Social Worker license in good standing

Valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation

STATE SPECIFIC REQUIREMENTS:

For the state of Wisconsin:

Bachelor's degree or more advanced degree in the human services area and a minimum of one (1) year experience working with at least one of the Family Care target populations; or

Bachelor's degree or more advanced degree in any area other than human services with a minimum of three (3) years' experience working with at least one of the Family Care target populations.

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.

#PJHS

#LI-AC1

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Case Manager, LTSS Iowa (Lee/Van Buren/Henry County) - Molina Healthcare
Posted: Sep 19, 2024 02:34
West Point, IA

Job Description

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

  • Completes face-to-face comprehensive assessments of members per regulated timelines.

  • Facilitates comprehensive waiver enrollment and disenrollment processes.

  • Develops and implements a case management plan, including a waiver service plan, in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

  • Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

  • Promotes integration of services for members including behavioral health care and long-term services and supports, home and community to enhance the continuity of care for Molina members.

  • Assesses for medical necessity and authorize all appropriate waiver services.

  • Evaluates covered benefits and advise appropriately regarding funding source.

  • Conducts face-to-face or home visits as required.

  • Facilitates interdisciplinary care team meetings for approval or denial of services and informal ICT collaboration.

  • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

  • Assesses for barriers to care, provides care coordination and assistance to member to address psycho/social, financial, and medical obstacles concerns.

  • Identifies critical incidents and develops prevention plans to assure member's health and welfare.

  • 50-75% local travel required.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

  • Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or master's degree in a social science, psychology, gerontology, public health or social work OR any combination of education and experience that would provide an equivalent background

REQUIRED EXPERIENCE:

  • At least 1 year of experience working with persons with disabilities/chronic conditions and Long Term Services & Supports.

  • 1-3 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED EXPERIENCE:

  • 3-5 years in case management, disease management, managed care or medical or behavioral health settings.

  • 1 year experience working with population who receive waiver services.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Active and unrestricted Certified Case Manager (CCM)

Active, unrestricted State Nursing license (LVN/LPN) OR Clinical Social Worker license in good standing

Valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation

STATE SPECIFIC REQUIREMENTS:

For the state of Wisconsin:

Bachelor's degree or more advanced degree in the human services area and a minimum of one (1) year experience working with at least one of the Family Care target populations; or

Bachelor's degree or more advanced degree in any area other than human services with a minimum of three (3) years' experience working with at least one of the Family Care target populations.

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.

#PJHS

#LI-AC1

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

IRIS SDPC (RN) - TMG (Jefferson County) (Fieldwork/Hybrid) (No Weekends, No Holidays, No After Hours) - Molina Healthcare
Posted: Sep 19, 2024 02:34
Fort Atkinson, WI

Job Description

Job Description

Job Summary

Are you seeking a unique nursing position that gives you a great work/life balance and lets you support people to live the lives that they choose? Then you'll want to keep reading about this rewarding work opportunity!

We are currently looking for a Registered Nurse licensed in Wisconsin to become our next IRIS Self-Directed Personal Care (SDPC) RN. This is a remote position, where you will partner with people in your community who are enrolled in the Wisconsin IRIS program - a Medicaid long-term care option for older adults and people with disabilities. People in the IRIS program who need personal care services have the choice to enroll in the IRIS Self-Directed Personal Care (IRIS SPDC) option. You can learn more about IRIS SDPC on the Wisconsin Department of Health Services website here (https://dhs.wisconsin.gov/iris/sdpc.htm) , and learn about the IRIS program here (https://dhs.wisconsin.gov/iris/index.htm) . While this role is home-based, you will have regularly scheduled visits with people in their homes and communities.

As an IRIS SDPC RN, you'll provide oversight and guidance to the people enrolled in the IRIS SDPC option. You'll also build relationships with the people you partner with and ensure that they're getting the most out of the IRIS Self-Directed Personal Care option through assessment, oversight, training and education.

IRIS SDPC RNs are responsible for administering the Wisconsin Personal Care Screening Tool; creating person-centered plans of care; providing personal care oversight to a group of people in IRIS, providing education and training for IRIS participants and care providers, and conducting the required documentation and follow-up. As an IRIS SDPC RN, you'll play an important role in helping people of various backgrounds and abilities live their lives the way they choose.

Knowledge/Skills/Abilities

  • Provides personal care assessments and oversight to the My Cares Groups by administering the Wisconsin Personal Care Screening Tool and addendums as required

  • Documents assessment as required by individual tool and Department of Health Services policies and by completing oversight visits and calls as required

  • Oversees a My Cares Groups of participants, develops individual plans of care, ensures physician orders for care are obtained and reviews and revises plan of care as needed

  • Submits for Prior Authorization for personal care services

  • Complies with all Department of Health Services policies and SDPC Guidelines, procedures, and practices along with documentation and program regulations

  • Provides personal care training to participants or care providers as requested and provides educational materials as needed

  • Completes collateral contacts with IRIS Consultants and Long-Term Care Functional Screeners and physicians to ensure care needs are met

  • Completes other duties as assigned

  • Overtime work may be required

  • May be required to drive 50% of the time during a given day of member home visits

  • Exposure to members homes which may include navigating stairs, exposure to different environments, and pets

Job Qualifications

REQUIRED EDUCATION:

Associates Degree in Nursing

REQUIRED EXPERIENCE:

  • Minimum 2 years of experience in nursing with at least one year of home health serving individuals with developmental disabilities, physical disabilities, or the elderly.

  • Demonstrated computer and software skills required, proficiency with Microsoft Office Suite and database operation/maintenance skills and data entry experience.

  • Excellent written and verbal communication skills required and the ability to adapt communication styles to fit situation.

  • Strong teaching and mentoring skills.

  • Strong analytical and problem-solving skills.

  • Good organizational and time management skills with ability to manage tasks independently.

  • Flexibility in the work environment and willingness and ability to adapt to changing organizational needs.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

Current unrestricted license in the state of Wisconsin as a Registered Nurse.

Valid Driver's License

PREFERRED EDUCATION:

Bachelor's Degree in Nursing

PREFERRED EXPERIENCE:

Experience providing care through the Wisconsin Medicaid Personal Care Program or one year of home care experience

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.

Pay Range: $26.41 - $51.49 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Behavioral Health Case Manager - Molina Healthcare
Posted: Sep 19, 2024 02:34
Charleston, SC

Job Description

JOB DESCRIPTION

Case Manager will work in remote and field setting supporting our Medicaid SMI (Severe Mental Illness) Population in the state of South Carolina. Case Manager will be required to communicate telephonically and complete Face to Face meetings. You will participate in interdisciplinary care team meetings for our members and ensure they have care plans based on their concerns/health needs. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important.

TRAVEL (30% or less) in the field to do member visits in the surrounding areas will be required.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

  • Completes clinical assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment.

  • Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

  • Conducts telephonic, face-to-face or home visits as required.

  • Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

  • Maintains ongoing member case load for regular outreach and management.

  • Promotes integration of services for members including behavioral health care and long term services and supports to enhance the continuity of care for Molina members.

  • May implement specific Molina wellness programs i.e. asthma and depression disease management.

  • Facilitates interdisciplinary care team meetings and informal ICT collaboration.

  • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

  • Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

  • Collaborates with RN case managers/supervisors as needed or required

  • Case managers in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed

  • Local travel of up to 40% may be required, depending on the complexity level of the assigned members, particular state-specific regulations, or whether the Case Manager position is located within Molina's Central Programs unit.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

Any of the following:

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or Master's Degree (preferably in a social science, psychology, gerontology, public health or social work or related

REQUIRED EXPERIENCE:

1-3 years in case management, disease management, managed care or medical or behavioral health settings.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

If license required for the job, license must be active, unrestricted and in good standing.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

STATE SPECIFIC REQUIREMENTS:

Roles serving Family Care and Family Care Partnership in the State of Wisconsin are required to have a Bachelor's Degree and a minimum of one year of professional experience.

PREFERRED EXPERIENCE:

3-5 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Any of the following:

Licensed Clinical Social Worker (LCSW), Advanced Practice Social Worker (APSW), Certified Case Manager (CCM), Certified in Health Education and Promotion (CHEP), Licensed Professional Counselor (LPC/LPCC), Respiratory Therapist, or Licensed Marriage and Family Therapist (LMFT).

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.

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Supervisor, Care Management - Molina Healthcare
Posted: Sep 19, 2024 02:34
Charleston, SC

Job Description

JOB DESCRIPTION

We are looking for a supervisor that must reside within the state of South Carolina. The Supervisor will manage a team of Case Managers that will support the South Carolina Severe Mental Illness Medicaid population.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

Oversees an integrated Care Management team responsible for case management, community connectors, health management, and/or transition of care activities to assist Molina Healthcare members with their healthcare needs. Care Management staff work to help members achieve optimal clinical, financial and quality of life outcomes, including safely and effectively transitioning Molina members from acute or inpatient care to lower levels of care and/or home in a cost-efficient manner.

  • Functions as a hands-on supervisor, providing direction and guidance to the care management team to ensure implementation of activities that align with the model of care and that meet regulatory requirements.

  • Manages staff caseloads and assigns cases appropriately regarding complexity of medical or psychosocial needs and case manager experience (RN, LSW, other allied fields).

  • Oversees the staff use of the electronic case management documentation system in compliance with standard Molina processes, standard documentation styles, and HIPAA. Arranges training as needed.

  • Manages, coaches and evaluates the performance of team members; provides employee development and recognition; and assists with selection, orientation and mentoring of new staff.

  • Promotes multidisciplinary collaboration, provider outreach, and engagement of family and caregivers to enhance the continuity of care for Molina members. Oversees and/or participates in Interdisciplinary Care Team meetings.

  • Works with the Manager to ensure adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators.

  • Audits case management assessments and care plan development for completeness and timeliness according to state requirements.

  • Monitors onsite hospital discharge visits and post-discharge visits to assure continuity of care and prevent unnecessary readmissions.

  • May monitor the completeness of the Transition of Care (ToC) assessment and the timeframes for contact are per ToC protocols.

JOB QUALIFICATIONS

Required Education

  • Registered Nurse or equivalent combination of Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) with experience in lieu of RN license.

  • OR Bachelor's or master's degree in gerontology, public health, or social work with related case management experience.

Required Experience

3 or more years in case management, disease management, managed care or medical or behavioral health settings.

Required License, Certification, Association

If licensed, license must be active, unrestricted and in good standing.

Preferred Education

Bachelor's or master's degree in Nursing,

Preferred Experience

More than five years Case Management experience. Medicaid/Medicare Population experience with increasing responsibility.

Preferred License, Certification, Association

Certified Case Manager (CCM), Certified Professional in Healthcare Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.

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.

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.



Job Detail

Behavioral Health Case Manager - Molina Healthcare
Posted: Sep 19, 2024 02:34
Chester, SC

Job Description

JOB DESCRIPTION

Case Manager will work in remote and field setting supporting our Medicaid SMI (Severe Mental Illness) Population in the state of South Carolina. Case Manager will be required to communicate telephonically and complete Face to Face meetings. You will participate in interdisciplinary care team meetings for our members and ensure they have care plans based on their concerns/health needs. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important.

TRAVEL (30% or less) in the field to do member visits in the surrounding areas will be required.

Home office with internet connectivity of high speed required.

Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

  • Completes clinical assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment.

  • Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.

  • Conducts telephonic, face-to-face or home visits as required.

  • Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

  • Maintains ongoing member case load for regular outreach and management.

  • Promotes integration of services for members including behavioral health care and long term services and supports to enhance the continuity of care for Molina members.

  • May implement specific Molina wellness programs i.e. asthma and depression disease management.

  • Facilitates interdisciplinary care team meetings and informal ICT collaboration.

  • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

  • Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

  • Collaborates with RN case managers/supervisors as needed or required

  • Case managers in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed

  • Local travel of up to 40% may be required, depending on the complexity level of the assigned members, particular state-specific regulations, or whether the Case Manager position is located within Molina's Central Programs unit.

JOB QUALIFICATIONS

REQUIRED EDUCATION:

Any of the following:

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR Bachelor's or Master's Degree (preferably in a social science, psychology, gerontology, public health or social work or related

REQUIRED EXPERIENCE:

1-3 years in case management, disease management, managed care or medical or behavioral health settings.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

If license required for the job, license must be active, unrestricted and in good standing.

Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

STATE SPECIFIC REQUIREMENTS:

Roles serving Family Care and Family Care Partnership in the State of Wisconsin are required to have a Bachelor's Degree and a minimum of one year of professional experience.

PREFERRED EXPERIENCE:

3-5 years in case management, disease management, managed care or medical or behavioral health settings.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Any of the following:

Licensed Clinical Social Worker (LCSW), Advanced Practice Social Worker (APSW), Certified Case Manager (CCM), Certified in Health Education and Promotion (CHEP), Licensed Professional Counselor (LPC/LPCC), Respiratory Therapist, or Licensed Marriage and Family Therapist (LMFT).

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.

Pay Range: $21.6 - $46.81 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Community Outreach & Engagement - Must Reside in Erie County NY - Molina Healthcare
Posted: Sep 18, 2024 07:12
Buffalo, NY

Job Description

Candidates For This Position Must Reside In/Near the Erie County Area

Are you passionate about serving others? Do you have established relationships within the community?

Come join our growing Community Engagement team at Molina Healthcare !

Community Outreach and Engagement is more than just participating in events- at Molina, we focus on making an impact on people's lives!

This role involves working with a wide variety of community partners to grow Molina's membership and improve the health and well-being of the Community. Our Specialists work collaboratively with our sales team and across Molina and with each other's regions. You would be responsible for managing events and community relationships in Erie and surrounding counties. You will be in the field engaging with CBO's (Community Based Organizations) 50% or more of the time (Molina reimburses mileage).

This position offers great flexibility and allows for you to manage your territory and schedule to meet business needs. Molina's leadership team leads with empowering you to do what you love best by helping others.

Bilingual (Spanish) Highly Desired!

*Candidates for this position must live in or near the Erie County Area*

KNOWLEDGE/SKILLS/ABILITIES

  • Responsible for achieving established goals improving Molina's enrollment growth objectives encompassing Medicaid programs. Works collaboratively with key departments across the enterprise to improve overall choice rates and assignment percentages.

  • Under limited supervision, responsible for carrying out enrollment events and achieving assigned membership growth targets through a combination of direct and indirect marketing activities, with the primary responsibility of improving the plan's overall -choice- rate. Works collaboratively with other key departments to increase the Medicaid assignment percentage for Molina.

  • Works closely with other team members and management to develop/maintain/deepen relationships with key business leaders, community-based organizations (CBOs) and providers, ensuring all efforts are directed towards building membership for Medicaid and related programs. Effectively moves relationships through the -enrollment- pipeline.

  • Responsible for achieving monthly, quarterly, and annual enrollment goals, and growth and choice targets, as established by management.

  • Schedules, coordinates & participates in enrollment events, encourages key partners to participate, and assists where feasible.

  • Works cohesively with Provider Services to ensure providers within assigned territory are aware of Molina products and services. Establishes simple referral processes for providers and CBOs to refer clients who may be eligible for other Molina products.

  • Viewed as a -subject matter expert- (SME) by community and influencers on the health care delivery system and wellness topics.

  • Delivers presentations, attends meetings and distributes educational materials to both members and potential members.

  • Assists with all incoming calls and assist perspective members or members with health access related questions.

  • Identify partnerships with key sponsorship opportunities and provide justification to determine Molina's participation.

  • Identify and promote Molina's programs out in the community and creates opportunities for employees to participate.

  • Responsible for managing their own daily schedule in alignment with department goals and initiatives as assigned by regions.

  • Key in the development of SMART goals and provide input on department priorities.

JOB QUALIFICATIONS

Required Education: Bachelor's Degree or equivalent, job-related experience.

Preferred Education: Bachelor's Degree in Marketing or related discipline.

Required Experience:

  • Min. 3 years of related experience (e.g., marketing, business development, community engagement, healthcare industry).

  • Demonstrated exceptional networking and negotiations skills.

  • Demonstrated strong public speaking and presentations skills.

  • Demonstrated ability to work in a fast-paced, team-oriented environment with little supervision.

  • Must be able to attend public events in outdoor venues in all weather conditions.

  • Must be able to sit and stand for long periods.

  • Must be able to drive up to 3 hours to attend events. Must be able to lift 30 pounds.

Required License, Certification, Association:

  • Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

Preferred Experience:

  • Solid understanding of Health Care Markets, primarily Medicaid.

  • Previous healthcare marketing, enrollment and/or grassroots/community outreach experience a plus.

  • 5 years of outreach experience serving low-income populations.

  • 3 - 5 years project management experience, preferably in a health care or outreach setting.

  • Experience presenting to influencer and low-income audiences.

  • Experience in sales or marketing techniques.

  • Fluency in a second language highly desirable.

Preferred License, Certification, Association:

  • Active Life & Health Insurance

  • Market Place Certified

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.

Key Words: health care, insurance, health insurance, Medicaid, Medicare, health coach, community health advisor, family advocate, health educator, liaison, promoter, outreach worker, peer counselor, patient navigator, health interpreter and public health aide, community lead, community advocate, nonprofit, non-profit, social worker, case worker, housing counselor, human service worker, Navigator, Assistor, Connecter, Promotora, Marketing, Sales, Growth, New York, MCO, Managed Care, ACA, FQHC, Behavioral Health, CHW, Community Health Worker, Equity, DPBH, HMO, SDOH

Pay Range: $16.23 - $35.17 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Claims Examiner (Medical) -Remote In Florida Only - Molina Healthcare
Posted: Sep 18, 2024 07:12
Boca Raton, FL

Job Description

Molina Healthcare of Florida is hiring for several Claims Examiners.

These positions are remote; however, all candidates must reside in the state of Florida .

Those with Health Insurance call center experience are encouraged to apply. This is an entry level position where you have the opportunity for growth & advancement.

As a Claims Examiner, you will be responsible for administering claims payments, maintaining claim records. Monitors and controls backlog and workflow of claims. Ensure that claims are settled in a timely fashion and in accordance with cost control standards.

KNOWLEDGE/SKILLS/ABILITIES

  • Evaluates the adjudication of claims using standard principles and state specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims.

  • Manages a caseload of claims. Procures all medical records and statements that support the claim.

  • Makes recommendations for further investigation or resolution.

  • Reduces defects via pro-active identification of error issues as it relates to pre-payment of claims through adjudication and trends and recommending solutions to resolve these issues.

  • Supports all department initiatives in improving overall efficiency.

  • Meets department quality and production standards.

  • Other duties as assigned.

JOB QUALIFICATIONS

Required Education : HS Diploma or GED

Preferred Education : Associate degree or equivalent combination of education and experience

Required Experience : 1-3 years of claims knowledge

Preferred Experience : 3-5 years of claims knowledge

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.

Key Words: Customer Service, Call Claims, Claims Processing, Adjustment, Claims, Trends, Reports, Denial and Claim, Appeals and Grievances, Data, Follow Up, Medicaid, Medicare, Managed Care, MCO, Codes, Processor, HMO, Bill, Adjust, Healthcare, Health Insurance

Pay Range: $12.19 - $26.42 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Analyst, Data - Molina Healthcare
Posted: Sep 18, 2024 07:12
Long Beach, CA

Job Description

* We are looking for candidate who can work in PST hours. ***

JOB DESCRIPTION Job Summary Designs and implements processes and solutions associated with a wide variety of data sets used for data/text mining, analysis, modeling, and predicting to enable informed business decisions. Gains insight into key business problems and deliverables by applying statistical analysis techniques to examine structured and unstructured data from multiple disparate sources. Collaborates across departments and with customers to define requirements and understand business problems. Uses advanced mathematical, statistical, querying, and reporting methods to develop solutions. Develops information tools, algorithms, dashboards, and queries to monitor and improve business performance. Creates solutions from initial concept to fully tested production, and communicates results to a broad range of audiences. Effectively uses current and emerging technologies. KNOWLEDGE/SKILLS/ABILITIES

  • Extracts and compiles various sources of information and large data sets from various systems to identify and analyze outliers.

  • Sets up process for monitoring, tracking, and trending department data.

  • Prepares any state mandated reports and analysis.

  • Works with internal, external and enterprise clients as needed to research, develop, and document new standard reports or processes.

  • Implements and uses the analytics software and systems to support the departments goals.

  • Must have advanced level working experience with MS Excel for data analysis, data validation and reporting.

  • Must have experience working in a healthcare environment.

  • Must be able to understand claims process and configuration.

  • Act as a tech support to claims teams.

JOB QUALIFICATIONS

Required Education

Associate's Degree or equivalent combination of education and experience

Required Experience

1-3 years

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

3-5 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.

Pay Range: $67,724.8 - $97,362.61 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Sr Claims Examiner Remote - Must Live In Florida - Molina Healthcare
Posted: Sep 18, 2024 07:12
Boca Raton, FL

Job Description

Molina Healthcare of Florida is hiring for several Sr. Claims Examiners.

These roles remote, however candidates must reside in Florida.

Ideal candidates will have experience with claims adjudication, claims edits, payout evaluation, front end claims processing, and Excel. QNXT experience a plus!

KNOWLEDGE/SKILLS/ABILITIES

  • Responsible for administering claims payments, maintaining claim records. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

  • Meets and consistently maintains production standards for Claims Adjudication.

  • Supports all department initiatives in improving overall efficiency.

  • Identifies and recommends solutions for error issues as it relates to pre-payment of claims.

  • Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication and recommending solutions to resolve these issues.

  • Monitors the medical treatment of claimants. Keeps meticulous notes and records for each claim.

  • Manages a caseload of various types of complex claims. Procures all medical records and statements that support the claim.

  • Meets department quality and production standards.

  • Meet State and Federal regulatory Compliance Regulations on turnaround times and claims payment for multiple lines of business.

  • Other duties as assigned.

JOB QUALIFICATIONS

Required Education : High School or GED

Preferred Education : Bachelor's Degree or equivalent combination of education and experience

Required Experience : 3-5 years claims processing required

Preferred Experience : 5-7 years claims processing preferred

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.

Key Words: Customer Service, Call Claims, Claims Processing, Adjustment, Claims, Trends, Reports, Denial and Claim, Appeals and Grievances, Data, Follow Up, Medicaid, Medicare, Managed Care, MCO, Codes, Processor, HMO, Bill, Adjust, Healthcare, Health Insurance, Front End Claims, Claims Processing, Excel

Pay Range: $13.41 - $29.06 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Investigator, Coding SIU (Remote) - Molina Healthcare
Posted: Sep 18, 2024 07:12
Owensboro, KY

Job Description

JOB DESCRIPTION

Job Summary

The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare fraud and abuse by medical providers. This position uses information from a tip, member benefits, and medical records to document relevant findings of a post pay clinical review. This position manages documents and prioritizes case load to ensure timely turn around. This position ensures adherence to state and federal policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or for payment recovery.

KNOWLEDGE/SKILLS/ABILITIES

  • Reviews post pay claims with corresponding medical records to determine accuracy of claims payments.

  • Review of applicable policies, CPT guidelines, and provider contracts.

  • Devise clinical summary post review.

  • Communicate and participate in meetings related to cases.

  • Critical thinking, problem solving and analytical skills.

  • Ability to prioritize and manage multiple tasks.

  • Proven ability to work in a team setting.

  • Ability to analyze data to identify FWA Trends

  • Excellent oral and written communication skills and presentation skills.

JOB QUALIFICATIONS

Required Education

High School Diploma / GED (or higher)

Required Experience

  • 3+ years CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience working in a FWA / SIU or Fraud investigations role for New Jersey/New York location

  • Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter)

Required License, Certification, Association

Certified Coder (CPC, CCS, and/or CPMA)

Preferred Education

Bachelor's degree (or higher)

Preferred Experience

  • 2+ years of experience working in the group health business preferred, particularly within claims processing or operations.

  • A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.)

  • Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.

  • Demonstrated ability to use MS Excel/Access platforms working with large quantities of data to answer questions or identify trends and patterns, and the ability to present those findings.

Preferred License, Certification, Association

  • AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred

  • Certified Fraud Examiner and/or AHFI professional designations preferred

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.

Pay Range: $19.64 - $42.55 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Provider Relations Manager - Molina Healthcare
Posted: Sep 18, 2024 07:12
Lincoln, NE

Job Description

*Remote and must live in Nebraska*

Job Description

Job Summary

Molina Health Plan Network Provider Relations jobs are responsible for network development, network adequacy and provider training and education, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Provider Relations staff are the primary point of contact between Molina Healthcare and contracted provider network. They are responsible for network management including provider education, communication, satisfaction, issue intake, access/availability and ensuring knowledge of and compliance with Molina healthcare policies and procedures while achieving the highest level of customer service.

Job Duties

This role serves as the primary point of contact between Molina Health plan and the Plan's Complex Provider Community that services Molina members, including but not limited to Value Based Payment and other Alternative Payment Method contracts. It is an external-facing, field-based position requiring an in-depth knowledge of provider relations and contracting subject matter expertise to successfully engage complex providers, including senior leaders and physicians, to ensure provider satisfaction, education on key Molina initiatives, and improved coordination and partnership.

- Under general supervision, works directly with the Plan's external complex providers to educate, advocate and engage as valuable partners, ensuring knowledge of and compliance with Molina policies and procedures while achieving the highest level of customer service.

- Resolves complex provider issues that may cross departmental lines including Contracting, Finance, Quality, Operations, and involve Senior Leadership.

- Responsible for Provider Satisfaction survey results.

- Develops and deploys strategic network planning tools to drive Provider Relations and Contracting Strategy across the enterprise.

- Facilitates strategic planning and documentation of network management standards and processes. Effectiveness is tied to financial and quality indicators.

- Works collaboratively with functional business unit stakeholders to lead and/or support various provider services functions with an emphasis on developing and implementing standards and best practices sharing across the organization.

- MCST matrix team environmental support including, but not limited to: New Markets Provider/Contract Support Services, PCRP & CSST resolution support, and National Contract Management support services.

- Serves as a subject matter expert for other departments.

- Conducts regular provider site visits within assigned region/service area. Determines own daily or weekly schedule, as needed to meet or exceed the Plan's monthly site visit goals. A key responsibility of the Representative during these visits is to proactively engage with the provider and staff to determine, for example, non-compliance with Molina policies/procedures or CMS guidelines/regulations, or to assess the non-clinical quality of customer service provided to Molina members.

- Provides on-the-spot training and education as needed, which may include counseling providers diplomatically, while retaining a positive working relationship.

- Independently troubleshoots problems as they arise, making an assessment when escalation to a Senior Representative, Supervisor, or another Molina department is needed. Takes initiative in preventing and resolving issues between the provider and the Plan whenever possible. The types of questions, issues or problems that may emerge during visits are unpredictable and may range from simple to very complex or sensitive matters.

- Initiates, coordinates and participates in problem-solving meetings between the provider and Molina stakeholders, including senior leadership and physicians. For example, such meetings would occur to discuss and resolve issues related to utilization management, pharmacy, quality of care, and correct coding.

- Independently delivers training and presentations to assigned providers and their staff, answering questions that come up on behalf of the Health plan. May also deliver training and presentations to larger groups, such as leaders and management of provider offices (including large multispecialty groups or health systems, executive level decision makers, Association meetings, and JOC's).

- Performs an integral role in network management, by monitoring and enforcing company policies and procedures, while increasing provider effectiveness by educating and promoting participation in various Molina initiatives. Examples of such initiatives include: administrative cost effectiveness, member satisfaction - CAHPS, regulatory-related, Molina Quality programs, and taking advantage of electronic solutions (EDI, EFT, EMR, Provider Portal, Provider Website, etc.).

- Trains other Provider Relations Representatives as appropriate.

- Role requires 60%+ same-day or overnight travel. (Extent of same-day or overnight travel will depend on the specific Health Plan and its service area.)

Job Qualifications

REQUIRED EDUCATION :

Bachelor's Degree in a healthcare related field or an equivalent combination of education and experience.

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES :

- 4-6 years provider contract network relations and management experience in a managed healthcare setting.

- Working experience servicing complex providers with various managed healthcare provider compensation methodologies, including but not limited to: fee-for service, value-based contracts, capitation and various forms of risk, ASO, etc.

PREFERRED EDUCATION :

Master's Degree in Health or Business related field

PREFERRED EXPERIENCE :

- 5 years experience in managed healthcare administration.

- Specific experience in provider services, operations, and/or contract negotiations in a Medicare and Medicaid managed healthcare setting, ideally with different provider types (e.g., physician, groups and hospitals).

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.

Pay Range: $54,373.27 - $117,808.76 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Claims Examiner (Medical) -Remote In Florida Only - Molina Healthcare
Posted: Sep 18, 2024 07:12
Tampa, FL

Job Description

Molina Healthcare of Florida is hiring for several Claims Examiners.

These positions are remote; however, all candidates must reside in the state of Florida .

Those with Health Insurance call center experience are encouraged to apply. This is an entry level position where you have the opportunity for growth & advancement.

As a Claims Examiner, you will be responsible for administering claims payments, maintaining claim records. Monitors and controls backlog and workflow of claims. Ensure that claims are settled in a timely fashion and in accordance with cost control standards.

KNOWLEDGE/SKILLS/ABILITIES

  • Evaluates the adjudication of claims using standard principles and state specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims.

  • Manages a caseload of claims. Procures all medical records and statements that support the claim.

  • Makes recommendations for further investigation or resolution.

  • Reduces defects via pro-active identification of error issues as it relates to pre-payment of claims through adjudication and trends and recommending solutions to resolve these issues.

  • Supports all department initiatives in improving overall efficiency.

  • Meets department quality and production standards.

  • Other duties as assigned.

JOB QUALIFICATIONS

Required Education : HS Diploma or GED

Preferred Education : Associate degree or equivalent combination of education and experience

Required Experience : 1-3 years of claims knowledge

Preferred Experience : 3-5 years of claims knowledge

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.

Key Words: Customer Service, Call Claims, Claims Processing, Adjustment, Claims, Trends, Reports, Denial and Claim, Appeals and Grievances, Data, Follow Up, Medicaid, Medicare, Managed Care, MCO, Codes, Processor, HMO, Bill, Adjust, Healthcare, Health Insurance

Pay Range: $12.19 - $26.42 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Sr Claims Examiner Remote - Must Live In Florida - Molina Healthcare
Posted: Sep 18, 2024 07:12
Tampa, FL

Job Description

Molina Healthcare of Florida is hiring for several Sr. Claims Examiners.

These roles remote, however candidates must reside in Florida.

Ideal candidates will have experience with claims adjudication, claims edits, payout evaluation, front end claims processing, and Excel. QNXT experience a plus!

KNOWLEDGE/SKILLS/ABILITIES

  • Responsible for administering claims payments, maintaining claim records. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

  • Meets and consistently maintains production standards for Claims Adjudication.

  • Supports all department initiatives in improving overall efficiency.

  • Identifies and recommends solutions for error issues as it relates to pre-payment of claims.

  • Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication and recommending solutions to resolve these issues.

  • Monitors the medical treatment of claimants. Keeps meticulous notes and records for each claim.

  • Manages a caseload of various types of complex claims. Procures all medical records and statements that support the claim.

  • Meets department quality and production standards.

  • Meet State and Federal regulatory Compliance Regulations on turnaround times and claims payment for multiple lines of business.

  • Other duties as assigned.

JOB QUALIFICATIONS

Required Education : High School or GED

Preferred Education : Bachelor's Degree or equivalent combination of education and experience

Required Experience : 3-5 years claims processing required

Preferred Experience : 5-7 years claims processing preferred

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.

Key Words: Customer Service, Call Claims, Claims Processing, Adjustment, Claims, Trends, Reports, Denial and Claim, Appeals and Grievances, Data, Follow Up, Medicaid, Medicare, Managed Care, MCO, Codes, Processor, HMO, Bill, Adjust, Healthcare, Health Insurance, Front End Claims, Claims Processing, Excel

Pay Range: $13.41 - $29.06 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Business Analyst (Claims - Remote FLORIDA) - Molina Healthcare
Posted: Sep 18, 2024 07:12
Tampa, FL

Job Description

JOB DESCRIPTION

*This position is remote and employee must reside in Florida*

Job Summary

Analyzes complex business problems and claims issues using data from internal and external sources to provide insight to decision-makers. Identifies and interprets trends and patterns in datasets to locate influences. Constructs forecasts, recommendations and strategic/tactical plans based on business data and market knowledge. Creates specifications for reports and analysis based on business needs and required or available data elements. Collaborates with clients to modify or tailor existing analysis or reports to meet their specific needs. May participate in management reviews, including presenting and interpreting analysis results, summarizing conclusions, and recommending a course of action. This is a general role in which employees work with multiple types of business data. May be internal operations-focused or external client-focused.

KNOWLEDGE/SKILLS/ABILITIES

  • Provides analytical, problem solving foundation within claims including: definition and documentation, specifications.

  • Recognizes, identifies and documents changes to existing business processes and identifies new opportunities for process developments and improvements.

  • Reviews, researches, analyzes and evaluates all data relating to specific area of expertise. Begins process of becoming subject matter expert.

  • Conducts analysis and uses analytical skills to identify root cause and assist with problem management as it relates to state requirements.

  • Analyzes business workflow and system needs for conversions and migrations to ensure that encounter, recovery and cost savings regulations are met

  • Prepares high level user documentation and training materials as needed.

JOB QUALIFICATIONS

Required Education

Associate's Degree or equivalent combination of education and experience

Required Experience

  • 3-5 Years of business analysis

  • 4+ years managed care experience

  • Demonstrates familiarity in a variety of concepts, practices, and procedures applicable to job-related subject areas.

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

  • 1-3 years formal training in Business Analysis and/or Systems Analysis

  • 1+ years claims background

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.

Pay Range: $19.64 - $42.55 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Business Analyst (Claims - Remote FLORIDA) - Molina Healthcare
Posted: Sep 18, 2024 07:12
Fort Lauderdale, FL

Job Description

JOB DESCRIPTION

*This position is remote and employee must reside in Florida*

Job Summary

Analyzes complex business problems and claims issues using data from internal and external sources to provide insight to decision-makers. Identifies and interprets trends and patterns in datasets to locate influences. Constructs forecasts, recommendations and strategic/tactical plans based on business data and market knowledge. Creates specifications for reports and analysis based on business needs and required or available data elements. Collaborates with clients to modify or tailor existing analysis or reports to meet their specific needs. May participate in management reviews, including presenting and interpreting analysis results, summarizing conclusions, and recommending a course of action. This is a general role in which employees work with multiple types of business data. May be internal operations-focused or external client-focused.

KNOWLEDGE/SKILLS/ABILITIES

  • Provides analytical, problem solving foundation within claims including: definition and documentation, specifications.

  • Recognizes, identifies and documents changes to existing business processes and identifies new opportunities for process developments and improvements.

  • Reviews, researches, analyzes and evaluates all data relating to specific area of expertise. Begins process of becoming subject matter expert.

  • Conducts analysis and uses analytical skills to identify root cause and assist with problem management as it relates to state requirements.

  • Analyzes business workflow and system needs for conversions and migrations to ensure that encounter, recovery and cost savings regulations are met

  • Prepares high level user documentation and training materials as needed.

JOB QUALIFICATIONS

Required Education

Associate's Degree or equivalent combination of education and experience

Required Experience

  • 3-5 Years of business analysis

  • 4+ years managed care experience

  • Demonstrates familiarity in a variety of concepts, practices, and procedures applicable to job-related subject areas.

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

  • 1-3 years formal training in Business Analysis and/or Systems Analysis

  • 1+ years claims background

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.

Pay Range: $19.64 - $42.55 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Investigator, Coding SIU (Remote) - Molina Healthcare
Posted: Sep 18, 2024 07:12
Covington, KY

Job Description

JOB DESCRIPTION

Job Summary

The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare fraud and abuse by medical providers. This position uses information from a tip, member benefits, and medical records to document relevant findings of a post pay clinical review. This position manages documents and prioritizes case load to ensure timely turn around. This position ensures adherence to state and federal policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or for payment recovery.

KNOWLEDGE/SKILLS/ABILITIES

  • Reviews post pay claims with corresponding medical records to determine accuracy of claims payments.

  • Review of applicable policies, CPT guidelines, and provider contracts.

  • Devise clinical summary post review.

  • Communicate and participate in meetings related to cases.

  • Critical thinking, problem solving and analytical skills.

  • Ability to prioritize and manage multiple tasks.

  • Proven ability to work in a team setting.

  • Ability to analyze data to identify FWA Trends

  • Excellent oral and written communication skills and presentation skills.

JOB QUALIFICATIONS

Required Education

High School Diploma / GED (or higher)

Required Experience

  • 3+ years CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience working in a FWA / SIU or Fraud investigations role for New Jersey/New York location

  • Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter)

Required License, Certification, Association

Certified Coder (CPC, CCS, and/or CPMA)

Preferred Education

Bachelor's degree (or higher)

Preferred Experience

  • 2+ years of experience working in the group health business preferred, particularly within claims processing or operations.

  • A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.)

  • Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.

  • Demonstrated ability to use MS Excel/Access platforms working with large quantities of data to answer questions or identify trends and patterns, and the ability to present those findings.

Preferred License, Certification, Association

  • AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred

  • Certified Fraud Examiner and/or AHFI professional designations preferred

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.

Pay Range: $19.64 - $42.55 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Claims Examiner (Medical) -Remote In Florida Only - Molina Healthcare
Posted: Sep 18, 2024 07:12
Fort Lauderdale, FL

Job Description

Molina Healthcare of Florida is hiring for several Claims Examiners.

These positions are remote; however, all candidates must reside in the state of Florida .

Those with Health Insurance call center experience are encouraged to apply. This is an entry level position where you have the opportunity for growth & advancement.

As a Claims Examiner, you will be responsible for administering claims payments, maintaining claim records. Monitors and controls backlog and workflow of claims. Ensure that claims are settled in a timely fashion and in accordance with cost control standards.

KNOWLEDGE/SKILLS/ABILITIES

  • Evaluates the adjudication of claims using standard principles and state specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims.

  • Manages a caseload of claims. Procures all medical records and statements that support the claim.

  • Makes recommendations for further investigation or resolution.

  • Reduces defects via pro-active identification of error issues as it relates to pre-payment of claims through adjudication and trends and recommending solutions to resolve these issues.

  • Supports all department initiatives in improving overall efficiency.

  • Meets department quality and production standards.

  • Other duties as assigned.

JOB QUALIFICATIONS

Required Education : HS Diploma or GED

Preferred Education : Associate degree or equivalent combination of education and experience

Required Experience : 1-3 years of claims knowledge

Preferred Experience : 3-5 years of claims knowledge

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.

Key Words: Customer Service, Call Claims, Claims Processing, Adjustment, Claims, Trends, Reports, Denial and Claim, Appeals and Grievances, Data, Follow Up, Medicaid, Medicare, Managed Care, MCO, Codes, Processor, HMO, Bill, Adjust, Healthcare, Health Insurance

Pay Range: $12.19 - $26.42 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Sr Claims Examiner Remote - Must Live In Florida - Molina Healthcare
Posted: Sep 18, 2024 07:12
Fort Lauderdale, FL

Job Description

Molina Healthcare of Florida is hiring for several Sr. Claims Examiners.

These roles remote, however candidates must reside in Florida.

Ideal candidates will have experience with claims adjudication, claims edits, payout evaluation, front end claims processing, and Excel. QNXT experience a plus!

KNOWLEDGE/SKILLS/ABILITIES

  • Responsible for administering claims payments, maintaining claim records. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

  • Meets and consistently maintains production standards for Claims Adjudication.

  • Supports all department initiatives in improving overall efficiency.

  • Identifies and recommends solutions for error issues as it relates to pre-payment of claims.

  • Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication and recommending solutions to resolve these issues.

  • Monitors the medical treatment of claimants. Keeps meticulous notes and records for each claim.

  • Manages a caseload of various types of complex claims. Procures all medical records and statements that support the claim.

  • Meets department quality and production standards.

  • Meet State and Federal regulatory Compliance Regulations on turnaround times and claims payment for multiple lines of business.

  • Other duties as assigned.

JOB QUALIFICATIONS

Required Education : High School or GED

Preferred Education : Bachelor's Degree or equivalent combination of education and experience

Required Experience : 3-5 years claims processing required

Preferred Experience : 5-7 years claims processing preferred

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.

Key Words: Customer Service, Call Claims, Claims Processing, Adjustment, Claims, Trends, Reports, Denial and Claim, Appeals and Grievances, Data, Follow Up, Medicaid, Medicare, Managed Care, MCO, Codes, Processor, HMO, Bill, Adjust, Healthcare, Health Insurance, Front End Claims, Claims Processing, Excel

Pay Range: $13.41 - $29.06 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Provider Relations Manager - Molina Healthcare
Posted: Sep 18, 2024 07:12
Kearney, NE

Job Description

*Remote and must live in Nebraska*

Job Description

Job Summary

Molina Health Plan Network Provider Relations jobs are responsible for network development, network adequacy and provider training and education, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Provider Relations staff are the primary point of contact between Molina Healthcare and contracted provider network. They are responsible for network management including provider education, communication, satisfaction, issue intake, access/availability and ensuring knowledge of and compliance with Molina healthcare policies and procedures while achieving the highest level of customer service.

Job Duties

This role serves as the primary point of contact between Molina Health plan and the Plan's Complex Provider Community that services Molina members, including but not limited to Value Based Payment and other Alternative Payment Method contracts. It is an external-facing, field-based position requiring an in-depth knowledge of provider relations and contracting subject matter expertise to successfully engage complex providers, including senior leaders and physicians, to ensure provider satisfaction, education on key Molina initiatives, and improved coordination and partnership.

- Under general supervision, works directly with the Plan's external complex providers to educate, advocate and engage as valuable partners, ensuring knowledge of and compliance with Molina policies and procedures while achieving the highest level of customer service.

- Resolves complex provider issues that may cross departmental lines including Contracting, Finance, Quality, Operations, and involve Senior Leadership.

- Responsible for Provider Satisfaction survey results.

- Develops and deploys strategic network planning tools to drive Provider Relations and Contracting Strategy across the enterprise.

- Facilitates strategic planning and documentation of network management standards and processes. Effectiveness is tied to financial and quality indicators.

- Works collaboratively with functional business unit stakeholders to lead and/or support various provider services functions with an emphasis on developing and implementing standards and best practices sharing across the organization.

- MCST matrix team environmental support including, but not limited to: New Markets Provider/Contract Support Services, PCRP & CSST resolution support, and National Contract Management support services.

- Serves as a subject matter expert for other departments.

- Conducts regular provider site visits within assigned region/service area. Determines own daily or weekly schedule, as needed to meet or exceed the Plan's monthly site visit goals. A key responsibility of the Representative during these visits is to proactively engage with the provider and staff to determine, for example, non-compliance with Molina policies/procedures or CMS guidelines/regulations, or to assess the non-clinical quality of customer service provided to Molina members.

- Provides on-the-spot training and education as needed, which may include counseling providers diplomatically, while retaining a positive working relationship.

- Independently troubleshoots problems as they arise, making an assessment when escalation to a Senior Representative, Supervisor, or another Molina department is needed. Takes initiative in preventing and resolving issues between the provider and the Plan whenever possible. The types of questions, issues or problems that may emerge during visits are unpredictable and may range from simple to very complex or sensitive matters.

- Initiates, coordinates and participates in problem-solving meetings between the provider and Molina stakeholders, including senior leadership and physicians. For example, such meetings would occur to discuss and resolve issues related to utilization management, pharmacy, quality of care, and correct coding.

- Independently delivers training and presentations to assigned providers and their staff, answering questions that come up on behalf of the Health plan. May also deliver training and presentations to larger groups, such as leaders and management of provider offices (including large multispecialty groups or health systems, executive level decision makers, Association meetings, and JOC's).

- Performs an integral role in network management, by monitoring and enforcing company policies and procedures, while increasing provider effectiveness by educating and promoting participation in various Molina initiatives. Examples of such initiatives include: administrative cost effectiveness, member satisfaction - CAHPS, regulatory-related, Molina Quality programs, and taking advantage of electronic solutions (EDI, EFT, EMR, Provider Portal, Provider Website, etc.).

- Trains other Provider Relations Representatives as appropriate.

- Role requires 60%+ same-day or overnight travel. (Extent of same-day or overnight travel will depend on the specific Health Plan and its service area.)

Job Qualifications

REQUIRED EDUCATION :

Bachelor's Degree in a healthcare related field or an equivalent combination of education and experience.

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES :

- 4-6 years provider contract network relations and management experience in a managed healthcare setting.

- Working experience servicing complex providers with various managed healthcare provider compensation methodologies, including but not limited to: fee-for service, value-based contracts, capitation and various forms of risk, ASO, etc.

PREFERRED EDUCATION :

Master's Degree in Health or Business related field

PREFERRED EXPERIENCE :

- 5 years experience in managed healthcare administration.

- Specific experience in provider services, operations, and/or contract negotiations in a Medicare and Medicaid managed healthcare setting, ideally with different provider types (e.g., physician, groups and hospitals).

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.

Pay Range: $54,373.27 - $117,808.76 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Business Analyst (Claims - Remote FLORIDA) - Molina Healthcare
Posted: Sep 18, 2024 07:12
Orlando, FL

Job Description

JOB DESCRIPTION

*This position is remote and employee must reside in Florida*

Job Summary

Analyzes complex business problems and claims issues using data from internal and external sources to provide insight to decision-makers. Identifies and interprets trends and patterns in datasets to locate influences. Constructs forecasts, recommendations and strategic/tactical plans based on business data and market knowledge. Creates specifications for reports and analysis based on business needs and required or available data elements. Collaborates with clients to modify or tailor existing analysis or reports to meet their specific needs. May participate in management reviews, including presenting and interpreting analysis results, summarizing conclusions, and recommending a course of action. This is a general role in which employees work with multiple types of business data. May be internal operations-focused or external client-focused.

KNOWLEDGE/SKILLS/ABILITIES

  • Provides analytical, problem solving foundation within claims including: definition and documentation, specifications.

  • Recognizes, identifies and documents changes to existing business processes and identifies new opportunities for process developments and improvements.

  • Reviews, researches, analyzes and evaluates all data relating to specific area of expertise. Begins process of becoming subject matter expert.

  • Conducts analysis and uses analytical skills to identify root cause and assist with problem management as it relates to state requirements.

  • Analyzes business workflow and system needs for conversions and migrations to ensure that encounter, recovery and cost savings regulations are met

  • Prepares high level user documentation and training materials as needed.

JOB QUALIFICATIONS

Required Education

Associate's Degree or equivalent combination of education and experience

Required Experience

  • 3-5 Years of business analysis

  • 4+ years managed care experience

  • Demonstrates familiarity in a variety of concepts, practices, and procedures applicable to job-related subject areas.

Preferred Education

Bachelor's Degree or equivalent combination of education and experience

Preferred Experience

  • 1-3 years formal training in Business Analysis and/or Systems Analysis

  • 1+ years claims background

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.

Pay Range: $19.64 - $42.55 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Sr Claims Examiner Remote - Must Live In Florida - Molina Healthcare
Posted: Sep 18, 2024 07:12
Orlando, FL

Job Description

Molina Healthcare of Florida is hiring for several Sr. Claims Examiners.

These roles remote, however candidates must reside in Florida.

Ideal candidates will have experience with claims adjudication, claims edits, payout evaluation, front end claims processing, and Excel. QNXT experience a plus!

KNOWLEDGE/SKILLS/ABILITIES

  • Responsible for administering claims payments, maintaining claim records. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

  • Meets and consistently maintains production standards for Claims Adjudication.

  • Supports all department initiatives in improving overall efficiency.

  • Identifies and recommends solutions for error issues as it relates to pre-payment of claims.

  • Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication and recommending solutions to resolve these issues.

  • Monitors the medical treatment of claimants. Keeps meticulous notes and records for each claim.

  • Manages a caseload of various types of complex claims. Procures all medical records and statements that support the claim.

  • Meets department quality and production standards.

  • Meet State and Federal regulatory Compliance Regulations on turnaround times and claims payment for multiple lines of business.

  • Other duties as assigned.

JOB QUALIFICATIONS

Required Education : High School or GED

Preferred Education : Bachelor's Degree or equivalent combination of education and experience

Required Experience : 3-5 years claims processing required

Preferred Experience : 5-7 years claims processing preferred

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.

Key Words: Customer Service, Call Claims, Claims Processing, Adjustment, Claims, Trends, Reports, Denial and Claim, Appeals and Grievances, Data, Follow Up, Medicaid, Medicare, Managed Care, MCO, Codes, Processor, HMO, Bill, Adjust, Healthcare, Health Insurance, Front End Claims, Claims Processing, Excel

Pay Range: $13.41 - $29.06 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail

Claims Examiner (Medical) -Remote In Florida Only - Molina Healthcare
Posted: Sep 18, 2024 07:12
Orlando, FL

Job Description

Molina Healthcare of Florida is hiring for several Claims Examiners.

These positions are remote; however, all candidates must reside in the state of Florida .

Those with Health Insurance call center experience are encouraged to apply. This is an entry level position where you have the opportunity for growth & advancement.

As a Claims Examiner, you will be responsible for administering claims payments, maintaining claim records. Monitors and controls backlog and workflow of claims. Ensure that claims are settled in a timely fashion and in accordance with cost control standards.

KNOWLEDGE/SKILLS/ABILITIES

  • Evaluates the adjudication of claims using standard principles and state specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims.

  • Manages a caseload of claims. Procures all medical records and statements that support the claim.

  • Makes recommendations for further investigation or resolution.

  • Reduces defects via pro-active identification of error issues as it relates to pre-payment of claims through adjudication and trends and recommending solutions to resolve these issues.

  • Supports all department initiatives in improving overall efficiency.

  • Meets department quality and production standards.

  • Other duties as assigned.

JOB QUALIFICATIONS

Required Education : HS Diploma or GED

Preferred Education : Associate degree or equivalent combination of education and experience

Required Experience : 1-3 years of claims knowledge

Preferred Experience : 3-5 years of claims knowledge

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.

Key Words: Customer Service, Call Claims, Claims Processing, Adjustment, Claims, Trends, Reports, Denial and Claim, Appeals and Grievances, Data, Follow Up, Medicaid, Medicare, Managed Care, MCO, Codes, Processor, HMO, Bill, Adjust, Healthcare, Health Insurance

Pay Range: $12.19 - $26.42 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.



Job Detail