AVP, Clinical Validation (PI)

$140,795 - $274,550/Yr

Molina Healthcare - Long Beach, CA

Full-time - Senior

Long Beach, CA

1,001-5,000 employees

Insurance Carriers and Related Activities

About the position

The AVP, Clinical Validation (PI) role at Molina Healthcare is a leadership position within the Payment Integrity department. This role is responsible for overseeing the Clinical Operations team, which includes clinical staff and certified coders, to enhance overpayment identification, drive savings, and manage administrative costs. The position collaborates with various departments to optimize operational and financial outcomes through effective clinical review processes.

Responsibilities

• Lead Molina's payment integrity Clinical Operations team overseeing Pre-pay and Post-pay DRG validation, Itemized Bill Review, and Medical Record Review processes.
• Validate coding accuracy including billed diagnosis, procedure codes, and billed charges supported by clinical information.
• Develop and refine content, oversee vendor content, and partner with root cause analysis teams to minimize dispute overturn rates.
• Provide strategic leadership for clinical review programs to enhance overpayment identification and manage costs.
• Foster a collaborative culture within the team to thrive in a fast-paced environment.
• Create and maintain DRG Validation clinical policies to support the Clinical review program.
• Analyze dispute overturn data to identify trends and maximize cost savings while reducing provider abrasion.
• Set up operational workflows with Shared Services to efficiently review claims and maintain compliance TAT requirements.
• Identify cost-saving opportunities in partnership with HP CMOs, Utilization Management, and Shared Services teams.
• Coach staff through sample auditing to improve DRG review quality.

Requirements

• Bachelor's Degree in Healthcare Administration or Health Information Management or relevant healthcare experience.
• Minimum of 7 years of healthcare experience in a related job or operational experience.
• 5+ years of managed care payor experience, preferably in Medicare/Medicaid.
• Rich understanding of ICD-9/10CM, MS-, AP- and APR-DRG reimbursement.
• 5+ years of experience in a leadership role with demonstrated success in managing a team.
• Experience with hospital EMRs, EPIC Payor Platform, and medical record repositories.
• Strong strategic thinking skills with the ability to translate strategy into operational goals.
• Excellent verbal and written communication skills.
• Ability to influence and drive change within the organization.

Nice-to-haves

• Master's Degree
• Coding Certification / Inpatient Coding Credential (CCS, CIC, CDIP or CCDS)
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)

Benefits

• Health insurance