Molina Healthcare - Louisville, KY
posted 3 months ago
The position is responsible for the accurate and timely production review of issues reported within the claims intake and processing ecosystem, which includes systems such as QNXT and Edifecs. The individual in this role will gain a comprehensive understanding of the solution functionality through thorough documentation review. They will identify the root cause of issues, validate these causes, and extrapolate the potential impact of the identified issues on the claims processing workflow. Additionally, the role involves validating data received on claims to identify any billing issues that could affect claims processing and payment. Monitoring new solutions implemented is also a key responsibility, as the individual will need to identify defects in the solution or configuration during the warranty period. This requires a strong knowledge of healthcare claims and the entire claims processing lifecycle, from receipt through encounter submission. The ideal candidate will possess knowledge of configuration in QNXT, claim pricing, and have strong SQL skills, as well as familiarity with Edifecs and healthcare EDI claims transactions. The role demands critical thinking skills to analyze claim processing issues effectively and the ability to collaborate with both internal and external stakeholders to gain a deeper understanding of the solutions in place. The candidate will be expected to possess or quickly gain a deep understanding of Molina's claims lifecycle and all processes that affect claims payment, with limited training and documentation available. The position may involve working on complex projects with some mentoring, as well as moderate to simple projects without mentoring. Researching issues and setting up proof of concept tests will also be part of the job responsibilities.