Director Core Systems Strategies – QNXT/NetworX

Job Summary

Leads and directs a team responsible for configuration activities, including the accurate and timely implementation and maintenance of critical information on claims databases. This role ensures the validation of data stored on databases and adherence to health plan business and system requirements pertaining to contracting, benefits, prior authorizations, fee schedules, and other business needs.

Essential Job Duties

• Directs the configuration team and is accountable for team performance, meeting or exceeding established performance targets based on specific health plan and/or federal/state requirements.
• Strategically plans, leads, and manages configuration workflow processes.
• Continuously identifies and executes opportunities for operational efficiencies and develops best practice approaches for assigned operational areas to achieve organizational/department goals.
• Ensures appropriate resources are available to achieve department goals, escalating resource needs, rationale, and deficiencies to leadership.
• Identifies and implements strategic process improvements related to the configuration function that demonstrate a return on investment (ROI).
• Establishes and maintains benefits, provider contracts, fee schedules, claims edits, and other system settings in the claims payment system.
• Directs the development and implementation of contract and benefit configuration, and fee schedules.
• Directs the implementation and maintenance of member benefits in the claims payment system and other applicable systems.
• Supports critical business strategies by providing systematic solutions and/or recommendations on business processes.
• Plans for the long-term success of the department and individual health plans, focusing on goals and improvements to daily operations.
• Builds and maintains strong, trusted relationships with key stakeholders, including health plan leadership and other cross-functional departments; presents data and opportunities to stakeholders and collaborates on performance improvement initiatives.
• Coordinates activities of assigned work functions and/or department-related activities, ensuring efficiency and prioritization.
• Utilizes superior judgment in evaluating various approaches to limit risk and communicates risk accordingly to appropriate stakeholders.
• Ensures appropriate follow-up and communication occurs on direct assignments, activities, and tasks within the scope of configuration.
• Ensures team compliance with applicable federal/state regulations and internal policies/procedures.
• Hires, trains, develops, and manages the team; demonstrates accountability for team performance and achievement of configuration/department-specific goals.

Required Qualifications

• At least 8 years of configuration oversight, claims, auditing, and/or healthcare operations experience in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or an equivalent combination of relevant education and experience.
• At least 3 years of management/leadership experience.
• Advanced understanding of claims processes.
• Advanced ability to identify and troubleshoot claim discrepancies using benefit and provider contracts, regulatory requirements, and various claims-related resources.
• Strong analytical, critical-thinking, and problem-solving skills.
• Strong multitasking and decision-making abilities.
• Flexibility to meet changing business requirements and a strong commitment to high-quality, on-time delivery.
• Ability to work cross-collaboratively in a highly matrixed organization.
• High attention to detail.
• Excellent verbal and written communication skills.
• Proficiency in Microsoft Office suite, including advanced Excel abilities (VLOOKUP/Pivot Tables, etc.), and applicable software programs.

Preferred Qualifications

• Certified Professional Coder (CPC).
• Extensive experience leading analysis and operational teams in a managed care setting.
• Extensive experience collaborating with various levels of leadership in a highly matrixed organization.
• Deep claims system processing, configuration, and queries experience.

Additional Information

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V